Method of chronic cardiac decompensation severity assessment using quantitative criteria for children with innate heart disease

FIELD: medicine.

SUBSTANCE: invention refers to medicine, particularly to infant cardiology, and can be applied in assessment of chronic cardiac disease (CD) severity for children with innate heard diseases. It involves determination of level indicator for T-terminal predecessor of cerebral natriuretic peptide (NT-pro-BNP) as quantitative criterion. For NT-pro-BNP level value within 15 to 214 pg/ml, 1 functional class of cardiac decompensation is diagnosed (FC 1); for level value within 141 to 898 pg/ml FC 2 is diagnosed, for level value within 962 to 4993 pg/ml FC 3 is diagnosed, for level value within 3626 to 78616 pg/ml FC 4 is diagnosed.

EFFECT: objective and prompt assessment of cardiac decompensation level for the claimed group of patients, enabling timely surgical treatment.

2 tbl, 1 ex

 

The invention relates to medicine, namely to pediatric cardiology, and allows you to specify the evaluation of the severity of patients with chronic heart failure (HF).

In clinical practice, there are different classifications for standardization of the assessment of patients. Recognized in the world classification of patients with chronic heart failure is a functional classification of new York heart Association - NYHA (1928) [1]. This classification is based on a purely functional principle of assessing the severity of patients CH no characteristic morphological changes and hemodynamic changes in a large and a small circle of blood circulation. According to this classification, there are the 4 functional class (FC) depending on tolerability patients physical activity. In children to determine the severity of heart failure NYHA use in the modification of Ross [2]. The feature of this classification is its descriptive nature. It is simple and easy to use in clinical practice and without additional surveys allows practitioners to establish the severity of heart failure. At the same time, one cannot fail to note the obvious - with all the advantages, NYHA classification based on rather subjective sensations assessment that may is rivality to differences in the definition of SN by different researchers. In addition, signs of heart failure in children are not specific for a long time may go unnoticed and be masked by other childhood diseases, such as diseases of the upper and lower respiratory tract infections, malnutrition, rickets. Objective criteria for severity of heart failure for children, such as other diseases (anemia - hemoglobin level, sepsis - level procalcitonin) does not exist.

Markers of chronic heart failure (CHF) and factor in the prognosis of this condition is cardiac natriuretic peptides B-type brain natriuretic peptide (BNP) and N-terminal fragment of the precursor of brain natriuretic peptide (NT-pro-BNP). When this indicator NT-pro-BNP has a number of advantages over index BNP:

1. NT-pro-BNP hormone is not active.

2. After production is in the blood for several days, the half-life of ~60-120 minutes

3. The cumulative level of NT-pro-BNP reflects myocardial function in General, not affected by circadian rhythms.

4. Very high stability in plasma (up to 5 days at room temperature).

Known diagnostic criteria of chronic heart failure (CHF) in adult patients depending on the level of NT-pro-BNP: chronic heart failure is unlikely to occur if values less than 300 PG/ml; high probability the spine pathology for patients younger than 50 years at rates ranging from 450 PG/ml and above, older than 50 years - from 900 PG/ml [3]. European society of cardiology has included the determination of natriuretic peptides in the list of required studies for screening of adult patients with high risk chronic heart failure, diagnosis of chronic heart failure in the early stages, to assess the effectiveness of treatment of chronic heart failure, to assess the prognosis of the disease [4].

The diagnostic criteria of chronic heart failure (CHF) in children with CHD can greatly facilitate the assessment of severity of HF in children with CHD, will allow for timely and effective treatment.

The aim of the proposed invention is the determination of quantitative criteria for assessing the severity of heart failure (HF) in children with congenital heart defects (CHD).

The essence of the invention is expressed by the set of essential features, sufficient to achieve the desired technical result, which consists in creating techniques to produce an objective assessment of the severity of HF in children with CHD.

The essence of the invention is that the method of assessing the severity of chronic heart failure with the use of quantitative criteria in children with congenital heart defects includes the use of classifications based on clinical manifestations, depending on tolerability patients physical activity. For bjectives and operational assessment of the severity of heart failure in these patients used the survey of the level of NT-pro-BNP.

From 2008 to 2009 at the Department of cardiac surgery children's Republican clinical hospital were studied 90 children with congenital heart disease prior to surgical correction. The age of patients varied from 1 day to 17 years (mean age 23 months), the average weight of 10.7 kg Ratio boys / girls: 45%/55%.

Depending on the severity of heart failure according to NYHA modification Ross [2] patients were distributed as follows: FC 21 children (23,3%), FC - 33 children (36,7%), FC - 13 children (14,4%), FC - 23 children (25,6%).

group 1 - patients children with CHD FC 1 (atrial septal defect (TSD) is 11 persons, ventricular septal defect (VSD) - 8 persons, aortic stenosis - 1, incomplete form of atrioventricular communication (AVC) - 1). The average age was 49 months.

group 2 - FC 2 - VSD - 11 people, TSD - 10 persons, AVK - 4 persons, TSD+partial anomalous drainage of pulmonary veins (CADL) - 3 people, transposition of the great arteries (TMS) with VSD and pulmonary artery stenosis - 2 people, single ventricle (is) - 2 people, aortic stenosis is 1 person Average age of 11 months.

group 3 - FC 3 - VSD - 7 persons, total anomalous drainage of pulmonary veins (TADL) - 2 people, AVK - 2 people, coarctation of aorta (Conducting) - 1 person, TMS with VSD and pulmonary artery stenosis is 1 person Average age of 3 months.

group 4 - FC 4 - TMS simple form - 5 people, with TMS VSD - 1 person, TADL - 3 people, hypoplasia of the aortic arch (GDS) - 2 people, Conducting - 2 people, VSD + GDS - 2 is eating., aorta-pulmonary window - 1 person, TMS + Conducting - 1 person, VSD + aortic stenosis - 1 person, VSD - 1 person, Conducting + VSD - 1 person, GDS + AVK - 1 person syndrome called hypoplastic left heart (SGLS) - 1 person, mitral valve insufficiency (NMC) total - 1 person Average age of 11 days.

We evaluated the relationship between the distribution of sick children the NYHA classification, and distribution of these patients by the level of NT-pro-BNP.

The results of the actual distribution of observed children are shown in table 1.

Table 1
The distribution of children with CHD gradation two classifications
Classes NYHANumber of childrenThe hormone level
FC 12115-214
FC 233141-898
FC 313962-4993
FC 4233626-78616
Total90

the since assessed the relationship between quantitative and qualitative indicators, it was decided to apply the technique of analysis of relationships using contingency tables by the algorithm proposed Samahito [5].

Background information transformed in table 2, and made calculations on the methods proposed Samahito [5].

Table 2
The paired distribution of patients according to the gradations of the two classifications
NYHAThe hormone level
200201-10001001-50005001 and moreTotal
FC 120121
FC 242933
FC 311213
FC 4 12223
Total2431132290

It was established that the degree of reliability of the link parameters of the compared classes is extremely high (p<0,001), and the estimation of the coupling strength, using the criterion Kramer, higher than 0.9, which is in correlation analysis corresponds to the level of the coefficient of determination R>0,81, but in practice is a basis to believe the compared rows of congruent distributions.

There is a relationship between the distribution of sick children of the NYHA classification and the distribution of these same patients on hormone levels of NT-pro-BNP allows to draw conclusions about what the definition of the level of NT-pro-BNP is an objective criterion of severity of heart failure in children with CHD. The use of this criterion in practice allows you to quickly and with a high degree of reliability to assess the severity of heart failure in children with CHD, facilitates timely surgical treatment, without the development of a critical state.

Currently, the most accurate and available for use in megaproto Inoi children's hospital, is the determination of NT-pro-BNP method electrochemiluminescence test system Elecsys ® pro-BNP on the instrument line Elecsys (Roche Diagnostic GmbH, Mannheim, Germany). "Elecsys ® pro-BNP" includes polyclonal antibodies that recognize epitopes located in the N-terminal part (1-76) pro-BNP. The analysis is not affected by conditions such as hemolysis, icterus, lipemia. NT-pro-BNP may be determined in serum and heparinized plasma.

Clinical example.

Patient A., female, age 5 months, East. bol. No. 0013156, was admitted to the paediatric ward Ronald McDonald 06.07.2009 year with complaints of shortness of breath, refusal to eat, pale skin. Respiratory rate (BH) 80 min, heart rate (HR)160 beats / min, liver +2 cm from the edge of the costal arch. Determined the level of NT-pro-BNP - 33035 PG/ml Condition regarded as decompensation of heart failure, further studies are diagnosed with a critical congenital heart defect (TADL). The child was successfully operated 14.07.09 in the Department of surgery. On the 7th day after the operation, the level of NT-pro-BNP declined to 6918 PG/ml Control examination at the age of 10 months: no complaints, skin physiological painting, BH - 30 min, heart rate 130 / min, liver at the edge of the costal arch.

Sources of information

1. The Criteria Committee of the New York Heart Association (1928). Diseases of the Heart and Blood Vessels: Nomenclature and Criteria for Diagnosis, 6th edtion. Boston, Mass: Little Brown & Co.; 1994.

2. Ross RD, Grading the severity of congestive heart failure in infants / Ross RD, Bollinger RO, Pinsky WW // Pediatr. Cardiol. - 1992. - Vol.13. No. 2. - P.72-75.

3. Januzzi J.L. Natriuretic peptide testing: A window into the diagnosis and prognosis of heart failure / Januzzi J.L. // Cleveland Clin. J. Med. - 2006. - Vol.73. No. 2. - P.149-152.

4. Guidelines for the diagnosis and treatment of chronic heart fealure. Task force for the diagnosis and treatment of Chronic Heart Fealure, European Society of Cardiology. // Eur. Heart J. - 2001. - Vol.22. No. 17. - P.1527-1560.

5. Vakhitov SH.M. the Analysis of relations in socially-hygienic studies using contingency tables: a manual for physicians. - Leningrad 1990. Pp.5-25.

The method of assessing the severity of chronic heart failure with the use of quantitative criteria in children with congenital heart defects, characterized in that determine the level of N-terminal fragment of the precursor of brain natriuretic peptide (NT-pro-BNP) in human serum or plasma and use it as a quantitative criterion, and when the value of the index from 15 to 214 PG/ml set 1 functional class of heart failure (FC), when the value from 141 to 898 PG/ml - FC, when the value from 962 until 4993 PG/ml - FC, when the value from 3626 to 78616 PG/ml - FC.



 

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