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Alyavi Anis Lutfullaevich, professor Kamilova Umida Kabirovna, professor E-mail: [email protected] Tulaganova Dildora Karimovna, Radjabova Diyora Iskandarovna, Shodiev Jasur Davlatovich, Republican Specialized Scientific-Practical Medical Center of Therapy and Medical Rehabilitation JSC, Uzbekistan
Structural-functional state and feature remodeling of left ventricle in patients with coronary artery disease after revascularization
Abstract: The article estimated the dynamics of systolic and diastolic function in patients with acute myocardial infarction after myocardial revascularization. The study involved 42 patients with acute myocardial infarction with ST segment elevation up to 6 hours of onset. Primary stenting of the infarct-related artery in patients with acute myocardial infarction with ST segment elevation allows most early as possible to prevent the development of pathological remodeling of the left ventricle compared with patients who underwent thrombolytic therapy as an effective and subsequent endovascular intervention.
Key words: acute myocardial infarction, revascularization, remodeling.
Rapid restoration of the vessel patency (reperfusion therapy) — the most effective way to reduce the risk of death and other adverse outcomes in patients with acute coronary artery occlusion occurred, regardless of the manner in which this is achieved [1]. Successful application of thrombolytic therapy has reduced mortality from acute myocardial infarction (AMI) to 20 %. However, lack of adequate restoration of antegrade flow in 45 % of cases, as well as a large number of contraindications to thrombolytic therapy and a high risk of bleeding complications contributed to the development and widespread use of an effective recovery method of endovascular coronary blood flow [2; 3].
Over the past decade it has increased the share of endovascular treatment of coronary heart disease (CHD) in the world. The choice of this treatment strategy of CHD, to counterbalance the surgical treatment in combination with conservative therapy caused the immediate efficacy and safety ofthe endovascular procedure to achieve adequate restoration of coronary blood flow in the majority of cases [4; 5; 6].
Primary endovascular restoration of coronary blood flow has several advantages over thrombolytic therapy. There is evidence that
reperfusion of the myocardium using the endovascular procedure is more than 95 % of patients with acute ST-segment elevation myocardial infarction (STEMI), then thrombolytic therapy restoration of blood flow is achieved only 70-75 % [7; 8].
A major randomized trial, which compared the results of angioplasty and thrombolytic therapy was the PAMI (Primary Angioplasty in Myocardial Infarction), which included 359 patients with acute myocardial infarction. 195 patients underwent angioplasty with the immediate success of 97.1 %. Interestingly, despite the minimal time from chest pain and ST-segment elevation before thrombolytic therapy than before PTCA restore myocardial perfusion disappearance of chest pain and normalization of the ST segment occurred rapidly after angioplasty than after thrombolytic therapy (mean 290 and 354 minutes, respectively; p = 0.004).
Endovascular method promotes effective limitation of the size of the damaged myocardium in the early stages of the onset of the disease, prevents the development of residual stenosis in the infarct-relat-ed artery (IRA) and pathological remodeling of the left ventricle (LV)
Section 4. Medical science
and as a result, leads to a reduction not only in-hospital mortality, but and improved survival of patients in distant periods [9; 10].
After the restoration of blood flow in some way in the area of the IRA is a change in contractility parameters, the geometry of the myocardium and central hemodynamics in general, which in turn determine the future course of the disease and the tactics of treatment. Today, in connection with the development and widespread use of modern methods of restoring coronary blood flow in AMIST, great attention is paid to the prevention of early pathological LV remodeling, which allows to influence the prognosis and survival ofpatients [11; 12].
Objective: To assess the dynamics of changes in systolic and diastolic function in patients with acute myocardial infarction after endovascular intervention.
Material and Methods: The study included 42 patients with STEMI up to 6 hours from the onset of the disease, ofwhich 39 men and 3 women. The average age of patients was 52.8 ± 3 years. Exclusion criteria included patients with stroke in anamnesis, with peripheral arterial disease, persistent atrial fibrillation, diabetes.
All patients were divided into 2 groups: the first group included 22 patients with STEMI who underwent stenting of the IRA. after the effective thrombolytic therapy within 24 hours of the onset of acute myocardial infarction, that identified like subocclusion defeat of the IRA during the control coronary angiography; the second group consisted of 20 patients with STEMI who underwent only thrombolytic therapy in the first 6 hours after the onset of myocardial infarction with a positive effect, without subsequent endovas-cular intervention. The effectiveness of the restoration of coronary blood flow was assessed by the degree of ST-segment to the contour in lead with a maximum rise to 7 days course of myocardial infarction using electrocardiographic (ECG) method.
All patients underwent echocardiography and doppler echocardiography study with the assessment of systolic and diastolic function of the left ventricle (LV) on the ultrasound machine Samsung medison «Accuvix.V20» (Korea) with a sector transducer with color mode and pulsed wave, continuous-wave mode with 2-4 MHz. frequency standard echocardiographic positions. It measured next size: the end-diastolic dimension (EDD LV), left ventricular end-systolic dimension (ESD LV), left ventricular end-diastolic volume (EDV LV), left ventricular end-systolic volume (ESV LV), stroke volume (SV) and ejection fraction (EF) of the left ventricle.
To evaluate the diastolic function of LV it was identified the maximum speeds used by the early and late LV filling (E/A), IVRT — isovolumetric relaxation time LV DT — deceleration time of early diastolic filling. The analysis of dynamics of linear and volumetric parameters of the left ventricle in the study was carried out in the "B" — mode, the left ventricular ejection fraction was calculated by the method of Simpson disks, segmental myocardial contractility was assessed by calculating the wall motion score index (WMSi) of LV at 1 and 7 days after the coronary flow recovery.
Statistical analysis was performed by parametric and non-parametric statistics using Student's t-test. Were considered statistically significant deviation at p < 0.05.
Results and Discussion: Results of the study found that the patients in group I to 7 days of flow infarction showed a significant increase in end-diastolic left ventricular size (EDD LV), ESD LV (p < 0.05) EDV LV (p < 0.05), SV (p < 0.05), except for ESV LV (p > 0.05). In group II patients after thrombolytic therapy showed a significant increase of ESD LV (p < 0.05), EDV LV, ESV LV, SV (p < 0.05) to 7 days of myocardial infarction, but the ESV LV did not undergo significant changes (p > 0.05) (Tab. 1).
Table 1. - Dynamics of left ventricular systolic function
Indicator I group P1 II group P2
1 day Day 7 1 day Day 7
EDD LV, mm 4.9 ± 0.13 5.4 ± 0.13 <0.05 4.9 ± 0.09 5 ± 0.08 > 0.05
ESV LV mm 3.6 ± 0.11 4.2 ± 0.01 <0.05 3.6 ± 0.07 3.9 ± 0.07 < 0.05
EDV LV, ml 109.8 ± 3.3 125.4 ± 3.8 <0.05 97.2 ± 2.9 128.3 ± 3.9 < 0.05
ESV LV ml 55.6 ± 3.2 57.3 ± 4.4 > 0.05 50.2 ± 2.4 61.5 ± 4.2 < 0.05
SV, ml 47 ± 2.7 73 ± 2.4 <0.05 50 ± 2.1 64 ± 1.9 < 0.05
EF, % 50.5 ± 1.3 55.9 ± 1.1 <0.05 51.2 ± 1.3 51.2 ± 1.2 > 0.05
Table 2. - Dynamics of left ventricular diastolic function
Indicator I group P1 II group P2
1 day Day 7 1 day Day 7
E/A 1.1 ± 0.06 1.2 ± 0.05 >0.05 1 ± 0.05 1.7 ± 0.2 <0.05
DT, ms 133 ± 11 127 ± 6.5 >0.05 131 ± 11.9 131 ± 4.9 >0.05
IVRT, ms 93.3 ± 5.8 99.9 ± 6.5 >0.05 105 ± 8.9 105 ± 8.9 <0.05
WMSi 1.2 ± 0.17 1.1 ± 0.02 >0.05 1.6 ± 0.04 1.2 ± 0.04 <0.05
Reduced ejection fraction (EF) below normal by the end of the first day mentioned in I, and in II group of patients. On day 7, the flow of MI there was a significant increase in ejection fraction — 6 % of baseline (p < 0.05) in group I. EF in group II remained consistently low (p > 0.05) from 1 to 7 day of myocardial infarction.
In patients of I (E/A = 1.1 ± 0.06) and II (E/A = 1.1 ± 0.05) groups by the end of the first day of myocardial infarction, despite the efficacy of thrombolytic therapy, formed pseudonormalization diastolic filling (Type 2). On day 7 research I (E/A = 1.2 ± 0.05),
(p < 0.05) patients also recorded pseudonormalization diastolic filling, which is probably due to the routine use of ^-blockers in all patients from the second day of treatment, and only in II group of patients on day 7 of AMI detected diastolic dysfunction of the left ventricle myocardium by restrictive type (E/A = 1.7 ± 0.2), (p < 0.05) (Tab. 2).
The deceleration time of early diastolic filling (DT) in both groups of patients on day 7 of MI did not undergo significant changes (p > 0.05). The wall motion score index of LV (WMSi LV) significantly decreased to 7 days of myocardial infarction only in
group II patients (p < 0.05). At the same time, the WMSi LV in group II significantly reduced from the first day of MI and significantly increased to day 7 (p < 0.05).
Thus, in II group of patients, despite effective thrombolytic therapy and subsequent endovascular treatment within the first to day 7 of the onset of the disease formed the early signs of pathological LV remodeling as increasing of EDD LV and ESD LV, SV and EDV LV. Thus, by the end of day 1, the development of myocardial infarction was noted pseudonormalization diastolic filling. For Group II, in addition to increasing EDV LV, ESV LV SV and ESD LV, and initially the most high of WMSi LV is characterized by the formation of prognostically unfavorable in relation to the development of pathological LV remodeling and heart failure as restrictive LV diastolic dysfunction, and persistent decrease in LV EF at compared with patients in group I.
The percentage of the degree of the ST- segment normalization regress, dilatation of the heart cavities, decreased left ventricular ejection fraction, high WMSi LV early pseudonormalization of diastolic dysfunction of the left ventricular myocardium, reducing the time isovolumetric relaxation of the left ventricle and the subsequent diastolic dysfunction LV myocardium of the restrictive type in the subacute phase of myocardial infarction, can serve as indepen-
dent predictors of adverse pathological criteria for the development of early postinfarction LV remodeling.
Conclusions. Stenting of the infarct-related artery in patients with STEMI maximizes prevent the development of early pathological LV remodeling in acute and subacute myocardial infarction flow period. Delayed endovascular procedure within a period of 6 to 24 hours after the completion of an effective thrombolytic therapy to be an additional improvement in intracardiac hemodynamics to 7 days course of myocardial infarction. Despite the effectiveness of thrombolytic therapy and even subsequent endovascular treatment within the first days of onset to 7 days form the first signs of early pathological LV remodeling in the form of increased end-systolic and end-diastolic dimensions of the left ventricle of the heart, stroke and end-diastolic volume of the left ventricle, and pseudonormalization the development of diastolic filling by the end of day 1 of myocardial infarction. Patients with effective thrombolysis without subsequent endovascular intervention within 24 hours from the onset of anginal attack have a poor prognosis in the development of early pathological ventricular remodeling and heart failure, as evidenced by the formation of restrictive diastolic dysfunction, and a characteristic statistically significant decrease in the isovolumetric relaxation time of LV myocardium.
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