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INVENTION
Patent of the Russian Federation RU2133467
METHOD OF DIAGNOSTICS OF MICROVASCULAR STENOCARDIA
IN PATIENTS WITH ISCHEMIC HEART DISEASE
The name of the inventor: Kudryavtsev SA; Alekseeva OP
The name of the patent holder: Military Medical Institute of the Federal Border Service of the Russian Federation at the Nizhny Novgorod State Medical Academy; Kudryavtsev Sergey Anatolyevich; Alexeeva Olga Polikarpovna
Address for correspondence: 603011, Nizhny Novgorod, per.Kazarmenniy, 1, VMI of the Federal Service of the Russian Federation with the NGMA NIRIO
Date of commencement of the patent: 1998.01.20
The method can be used in the field of medicine, in particular cardiology, and is intended for the diagnosis of microvascular angina in patients with ischemic heart disease (IHD). In patients with CHD in the morning hours, on an empty stomach, the saliva is collected, the collected saliva is centrifuged for 10 minutes at 3000 rpm, dilution in distilled water 1: 100 is prepared from a proprietary layer of saliva centrifugate and then the sample of the test solution and reference samples of the basic standard solution are analyzed By the method of flame photometry at a flame temperature of 1200 ° C., the rate of feeding the samples into the flame zone depends on the diaphragm and the sensitivity of the instrument, after which the potassium (K) and sodium (Na) content in the test sample is calculated from the formula 
Where Co is the concentration of K or Na in mg% in the test sample; E o is the extinction of the test sample; E min is the smallest extinction of the standard closest to the test sample; E max is the largest extinction of the standard closest to the test sample; Cmax is the concentration of K or Na in mg, corresponding to the greatest extinction; C min is the concentration of K or Na in mg, corresponding to the smallest extinction. Coefficient of conversion by SI system from mg% in mmol / l for potassium 0,256, for sodium 0,435. The results of the study in this case will be expressed in mmol / l, and if the content of K <29.5 mmol / l and Na <22.6 mmol / l, microvascular angina is diagnosed in patients with IHD. The method is simple, cheap, harmless, acceptable for the examinees and staff, and expands the arsenal of methods for diagnosing MS in IHD patients with diagnostic accuracy of 78%.
DESCRIPTION OF THE INVENTION
The proposed method relates to medicine, in particular to cardiology, and is intended for the diagnosis of microvascular angina in patients with ischemic heart disease (CHD).
Microvascular angina pectoris is one of the forms of coronary heart disease with unchanged subepicardial coronary arteries, and this angina in clinical practice is widely referred to as cardiac syndrome X. MS is characterized by the presence of angina pectoris tension, ischemic depression of the ST segment on an electrocardiogram (ECG) At the time of physical exertion, and the absence of signs of stenosing coronary atherosclerosis in selective coronary angiography [1, 2].
The method of selective coronarography is the closest in the aggregate of essential features to the proposed method and is selected by the authors as a prototype.
The known method consists in the following: under local anesthesia with 0.25-0.5% solution of novocaine, percutaneous puncture of the femoral artery is performed, then retrograde catheterization of the ascending part of the aorta is performed with pre-modeled catheters followed by alternate selective catheterization of the coronary arteries and the introduction of a water-soluble radiocontrast substance. The introduction of contrast is carried out either by a syringe from the hand, or by means of an automatic injector with pre-established modes of input speed and volume of the injected substance. During the introduction of the radiopaque solution, the x-ray image of the contrasted coronary arteries is photographed on a film at a rate of 25 frames per second. The condition of the left coronary artery is evaluated in 4 projections: a right oblique 30 ° with caudal angulation of 10 ° , a right oblique 30 ° with cranial angulation of 20 ° , a left oblique 40 ° with cranial angulation of 30 ° (4 chamber projection) and a left lateral . The right coronary artery is evaluated in 3 projections: the left oblique 60 ° , the left oblique 15 ° with cranial angulation 30 ° , the right oblique 30 ° .
The absence of signs of atherosclerotic lesion of subepicardial coronary arteries on the coronarogram, as well as the slow filling of the SC with contrasted blood and its prolonged leaching serve as the basis for the diagnosis of microvascular angina [3].
The known method is accurate, since it gives complete information about the radiographic anatomy of subepicardial CA. Selective coronary angiography, developed and implemented in clinical practice by Judkins M., is intended for objective visualization of coronary arteries and major branches, study of their anatomical and functional state, degree and nature of lesion of the atherosclerotic process, compensatory collateral circulation, distal coronary arteries.
At the same time, this method is technologically complex and accordingly expensive. For the implementation of the known method, special training of qualified nursing staff is necessary. From the point of view of safety, this method as a surgical, invasive manipulation is potentially dangerous for the day of the examinee and is not harmful to performers from the position of systematic exposure of their body to x-ray irradiation [4].
The task of the proposed method is simplicity, cheapness, harmlessness, acceptability for the subjects and personnel, and the expansion of the arsenal of methods for diagnosis of microvascular angina in patients with IHD.
The task is solved by the proposed method, including the analysis of a biological object, the determination of its parameters by a physicochemical method, and the diagnosis of the disease according to the magnitude of the object's parameters. According to the invention, saliva is taken as a biological object in IHD patients, it is separated, the clear part is diluted 1: 100 with water and then The reference samples and the sample of the test solution are analyzed by flame photometry at a flame temperature of 1200 ° C, the rate of sample feeding into the flame zone depends on the diaphragm and the sensitivity of the instrument, after which the potassium and sodium content in the test sample is calculated from the formula 
Where C o is the concentration of K or Na in mg% in the test sample;
E o - extinction of the test sample;
E min is the smallest extinction of the standard closest to the test sample;
E max is the greatest extinction of the standard closest to the test sample;
Cmax is the concentration of K or Na in mg, corresponding to the greatest extinction;
C min is the concentration of K or Na in mg corresponding to the smallest extinction, and with a K content of 29.5 mmol / L and Na <22.6 mmol / l, microvascular angina is diagnosed in IHD patients.
Distinctive features are that saliva is taken as a biological object in IHD patients, it is separated, the clear part is diluted 1: 100 with water and then the reference samples and sample of the test solution are analyzed by flame photometry at a flame temperature of 1200 ° C, Flame depends on the size of the diaphragm and the sensitivity of the instrument, after which the content of potassium and sodium in the test sample is calculated from the formula 
Where C o is the concentration of K or Na in mg% in the test sample;
E o - extinction of the test sample;
E min is the smallest extinction of the standard closest to the test sample;
E max is the largest extinction of the standard closest to the test sample;
Cmax is the concentration of K or Na in mg, corresponding to the greatest extinction;
C min is the concentration of K or Na in mg corresponding to the smallest extinction, and with a K content of 29.5 mmol / L and Na <22.6 mmol / l, microvascular angina is diagnosed in IHD patients.
The choice of saliva as an object of study is explained by the fact that the most optimal in terms of accessibility of the study of microcirculation (MC) are the salivary glands, the tissue of which is sufficiently densely provided with an abundant network of capillaries [5]. Such available parameters of salivary apparatus functioning as the rate of salivation and biochemical composition of blood will inevitably depend on the state of the microcirculatory bed, which actively participates in the formation of a set of non-digestive features of this organ, namely:
1) the intensity of blood flow at a functional load (about 800 ml / min / 100 g of tissue), the salivary gland is superior to the brain, myocardium, and kidneys. Such intensity of blood flow can not be explained in the narrow framework of only the digestive function of the salivary glands [5, 6];
2) the rate of salivation during the day ranges from 0.05 ml / min during sleep to 10 ml / min or more with the stimulation of salivation (the average amount of saliva secreted by the salivary glands per day in adults is 1500 ml and may increase with the stimulation of salivation to 10-12 liters per day), the volume of saliva is completely determined by the activity of the secretory endings, since the duct system does not reabsorb and does not add water to the saliva [7];
3) the complex biochemical composition of saliva, qualitatively not inferior to blood, and testifies in favor of the existence of non-digestive function of the salivary apparatus. Data on the biochemical composition of saliva are most fully represented in many works [8, 9].
Using certain indicators of the salivary function, it is possible to indirectly assess the condition of MC not only in the salivary glands, but also at the general organism level and at the level of the MC of the coronary bed in patients with IHD. The well-known fact that MS is the result of generalized endothelial or vascular dysfunction of the body, and not just of small heart CA [10; eleven]. It is suggested that this disorder is due to a disturbance in the production of endothelial cells of nitric oxide (NO) or other biologically active vasodilating substances, and due to a decrease in the sensitivity of smooth muscle cells to these vasoactive substances [12]. This leads to a logical conclusion that a violation of MC in MS can be recorded not only at the level of the CA, but also in other peripheral organs and tissues of the whole organism.
It is known that metabolic disorders are at the heart of any metabolic disorder, and potential-forming elements of the transmembrane system of the cell, such as potassium and sodium, play a role in this. The determination in the saliva of these electrolytes is due to their general-body significance and wide use in other physiological studies and clinical practice [13; 14; 15]. There are hypothetical assumptions that during the myocardial ischemia there is an accumulation of potassium in the extracellular space, which causes a change in the action of the potentials. It is proved that a decrease in potassium pump efficiency can lead to accumulation of potassium during intensive myocardial work. The uneven accumulation of potassium in the extracellular space can explain the appearance of electrical changes on the ECG during exercise, as well as other cardiac and extracardiac manifestations in MS patients [16]. Sodium, in turn, due to the disruption of the function of transmembrane systems accumulates intracellularly, and the important point is that the accumulation occurs in endothelial cells, which in this connection increases the sensitivity to constrictive substances (angiotensin, noradrenaline, etc.) [17] .
Analysis of scientific and technical and patent documentation showed that the proposed method is new and corresponds to the criterion of "inventive level".
The proposed method is carried out in the following way: in patients with IHD who are diagnosed with this diagnosis, in the morning, on an empty stomach, for 10 minutes they collect saliva. The collected saliva is centrifuged for 10 minutes at 3000 rpm. A clearing of the saliva centrifuge is prepared by dilution with distilled water 1: 100. Simultaneously with obtaining the experimental dilution, a basic standard solution is prepared for obtaining reference solutions and constructing a calibration schedule. The basic standard solution is obtained from twice recrystallized chemically pure salts of sodium chloride and potassium chloride, dried to constant weight (NaCI can be calcined and cooled in a desiccator) [18].
Dilutions of 100 ml 1: 10, 1: 15, 1:20, etc., are prepared on the basis of a common standard solution. With a known concentration of potassium and sodium (Table 1).
Using the method of flame photometry according to the corresponding indications of the scale of the galvanometer, extinctions are recorded for potassium and sodium in all dilutions of the basic standard solution and in experimental dilution of saliva. Based on the obtained extensions of standard dilutions, a calibration plot is constructed in the coordinate system for sodium and separately for potassium [19].
The obtained indications are mathematically processed below the formula given for determining the concentration of potassium and sodium in saliva in mg% 
Where C o is the concentration of K or Na in mg% in the test sample;
E o - extinction of the test sample;
E min is the smallest extinction of the standard closest to the test sample;
E max is the greatest extinction of the standard closest to the test sample;
Cmax is the concentration of K or Na in mg, corresponding to the greatest extinction;
C min is the concentration of K or Na in mg, corresponding to the smallest extinction.
Coefficient of conversion by SI system from mg% in mmol / l for potassium 0,256, for sodium 0,435. The results of the study in this case will be expressed in mmol / l.
The point of separation (value) for the potassium level is 29.5 mmol / l and for sodium it is 22.6 mmol / l. This value is determined by the successive Wald analysis and the Bayes formula [20]. With a combination of K <29.5 mmol / L and Na <22.6 mmol / L, the test is considered positive, indicating MS in patients with IHD. At values exceeding the established critical level for potassium and / or sodium in saliva, the test is considered negative, excluding MS and testifies in favor of stenosing coronary artery atherosclerosis.
35 patients with MS (main group) and 35 patients with coronary artery disease with stenosing arteriosclerosis of SC (comparison group) were examined by the proposed method. The anatomo-morphological state of SC was evaluated in all patients with the help of SCG (prototype), therefore this method served not only as a prototype, but also as a reference method for comparative diagnostic effectiveness of the proposed method.
To assess the accuracy of the proposed diagnostic method, the conventional operational characteristics, namely sensitivity and specificity, were used, and the predictive value of the positive test, the predictive value of the negative test, and the diagnostic accuracy of the method were calculated to evaluate the predictive probability of the method [21]. The results of the analysis of the diagnostic accuracy of the proposed method are shown in Table. 2.
The sensitivity of the sample was determined by the percentage of positive results of the proposed method in MS patients. Specificity was determined by the percentage of negative results of the proposed method in patients with ischemic heart disease with stenosing arteriosclerosis. The predictive value of a positive test was determined as the probability (in percent) of true-positive results among all positive tests. The predictive value of the negative test was expressed as a percentage of true negative results among all negative tests. The diagnostic accuracy of the method means the proportion of true results among all test results [21].
Specific examples of using the proposed method
Example 1
Extract from the medical history of N 1848 patient with coronary artery disease with stenotic atherosclerosis of the SC.
Patient Petrov Vladimir Petrovich, 48 years old, was in the department of IHD of the specialized clinical cardiosurgical hospital (SKKB) in N.Novgorod from 22.11.96 to 11.12.96. Years. With the diagnosis: IHD, angina pectoris, II CK. Postinfarction cardiosclerosis.
Over the past two years, he complains of compressive, retrosternal pain associated with physical exertion, dosed with nitroglycerin.
The signs of myocardial ischemia are confirmed by electrocardiography and echocardiography during the veloergometric test (VEP).
SCG (prototype): Right type of coronary circulation (PTCA), anterior descending artery occlusion, stenosis in the proximal segment of the envelope of the left coronary artery branch, stenosis at the mouth of the posterior descending artery.
The proposed method of the patient was analyzed saliva, taken on an empty stomach. The content in the sample is Na> 22.6 (22.7) mmol / l, K> 29.5 (29.6) mmol / l, which corresponds to coronary artery disease with stenosing coronary atherosclerosis
Example 2
Extract from the medical history of N 319 patients with microvascular angina.
Patient Sergey A. Pynin, 48 years old, was in the department of IHD SKKB of Nizhny Novgorod from 29.01.96 to 18.02.96. With the diagnosis: IHD, microvascular angina, CK II, NKO, cardiological syndrome-X.
She considers herself ill since November 1995, the main complaint is the pressing pains behind the sternum, arising during the load and being stopped by the intake of nitroglycerin.
The signs of myocardial ischemia are confirmed electrocardiographically during VEP and with daily monitoring by Holter.
SKG (prototype): the right type of coronary circulation. There is no atherosclerotic lesion of the coronary arteries. There is a slowdown in the evacuation of contrast medium from the coronary bed (more than 9 systoles).
The proposed method of the patient was analyzed saliva, taken on an empty stomach. The content in the sample is Na <22.6 (22.5) mmol / l, K <29.5 (29.4) mmol / l, which corresponds to microvascular angina.
Example 3
Extract from the medical history of N 3092 patient with microvascular angina
Patient Semenov Pavel Alexandrovich, 42 years old, was in the department of IHD SKKB of N.Novgorod from 22.12.95 to 5.01.96. With the diagnosis: IHD, microvascular angina, CK III, NKO, cardiological syndrome-X. Complaints of pressing pains behind the sternum and stitching in the precardial region, arising from physical exertion and psychoemotional stress, irradiating to the left arm and shoulder blade, are stopped by corinphar and nitroglycerin.
The signs of myocardial ischemia are confirmed electrocardiographically during VEP and with daily monitoring by Holter.
SKG (prototype): The right type of coronary circulation. The contours of the coronary arteries are even, there is no constriction, there is a delay in contrast in the vessels (more than 8 systoles). There is no atherosclerotic lesion of the coronary arteries.
The proposed method of the patient was analyzed saliva, taken on an empty stomach. The content in the sample is Na <22.6 (21.0) mmol / l, K <29.5 (27.1) mmol / l, which corresponds to microvascular angina.
As can be seen from the obtained results, the proposed method is simple, cheap, harmless, acceptable and extends the arsenal of methods for diagnosing MS in IHD patients with diagnostic accuracy of 78%.
USED BOOKS
1. Cannon RO The coronary microcirculation in heart disease: Hypertrophic cardiomyopathy, hypertension, and microvascular angina // Coronary Artery Dis. -1992. -Vol.3. -P.555- 563.
2. Drexler H., Schroeder JS Unusual forms of ischemic heart disease // Curr. Opin. CardioL -1994. -Vol.9, 4. -P.457-464.
3. Prototype of Judkins MP Selective coronary arteriography: 1. A percutaneous transfemoral techniqve // Radiology -1967, -Vol.89. - P.815.
4. Petrosyan Yu.S., Zingerman LS Coronarography. - Moscow: Medicine, 1974. -152 p.
5. Komarova LG, Alekseeva OP New ideas about the function of the salivary glands in the body (clinical and biochemical aspect) // Monograph. - N.Novgorod. -1994. -96 sec.
6. Netahata Zh.N., Lyapun SN. The study of salivation in humans in the norm and in pathology // Klin. honey. -1972. -T. 50, 9. - P. 15-22.
7. Romacheva IF, Yudin LA, Afanasyev. Diseases and lesions of the salivary glands. Moscow: Medicine, 1987. - 238 p.
8. Flusser I., Dvoretsky K., Geller J. et al. New views on the significance of the salivary glands // Chekhoslav. honey. Review. - 1973. - T. 19, N 1. - P.40-51.
9. Ferguson DB, Botchway CA A Comparison of circulation in the flow rate and composition of stimulated human purotid, supmandibular and whole salvivas from one same individuals // Arch. Oral. Biol. -1980. -Vol. 25, No. 8/9. - P. 559-568.
10. Pignocchino P., Conte MR, Scarnato S., Grande A. [Study of cutaneous microcirculation using the laser-Doppler method in syndrome X] [Lo studio del microcircolo cutaneo con metodica laser Doppler nella sindrome X.] // Cardiologia ( Italian). -1994. -Vol.39, -N 3. -P. 193-197.
11. Sax FL, Cannon RO Ill, Hanson C., Epstem SE Impaired forearm vasodilator. Reserve in patients with microvascular angina: Evidence of a generalized vascular function. N. Engl. J. Med. -1987. -Vol. 317.-P. 1366- 1370.
12.Wennmalm A., Albetsson P., Emanuelsson H. Patients with microvascular angina have a disturbance of endothelial-dependent forearm vasodilation // J. Vase. Res. -1992. -Vol. 26.-P. 225.
13. Bayevsky PM Prediction of states on the verge of norm and pathology. -M .: Medicine, 1979. - P. 116.
14. Borisov G.F. Sodium / potassium coefficient of saliva of the parotid glands in patients with cholecystitis // Kazan Medical. Journal. - 1980.-N3. -C.53-54.
15. Zaks M. G., Nikitin V.N. Ontogenesis of the digestive function // Age physiology. - L., 1975.-C. 263-312.
16. Poole-Wilson, RA, Crake, T. The enigma of syndrome X, Int. J. Microcirc. Clin. Exp. - 1989. -Vol.8, N 4.-P.423-432.
17. Zimin Yu.V. Insulin resistance, hyperinsulinemia and arterial hypertension // Cardiology. -1996. N 11.-C. 80-91.
18. Menshikov VV Methods of clinical biochemistry of hormones and mediators. Textbook (Part II). -M., -1974. (1 Moscow Medical Institute named after IM Sechenov). -179 s.
19. Kolb SG, Kamyshnikov VS Determination of electrolytes by the method of flame photometry // Clinical Biochemistry. -Minsk: Belarus, 1976.-C. 184-189.
20. Gubler EV Computational methods of analysis and recognition of pathological processes. L., "Medicine", 1978, 294 p.
21. Vlasov V.V. The effectiveness of diagnostic studies - M .: Medicine, 1988.-241 p.
CLAIM
The method of diagnosis of microvascular angina in patients with ischemic heart disease (IHD), including the analysis of a biological object, the determination of its parameters by a physico-chemical method and diagnosis of the disease according to the magnitude of the object's parameters, characterized in that saliva is taken as a biological object in patients with IHD, The transparent part is diluted 1: 100 with water and then the reference samples and sample of the test solution are analyzed by flame photometry at a flame temperature of 1200 ° C, the rate of sample feeding into the flame zone depends on the diaphragm and sensitivity of the instrument, after which the potassium (K) and sodium (Na) in the experimental sample ao of formula 
Where C o is the concentration of K or Na in mg% in the test sample;
E o is the extinction of the test sample;
E min is the smallest extinction of the standard closest to the test sample;
E max is the greatest extinction of the standard closest to the test sample;
Cmax is the concentration of K or Na in mg, corresponding to the greatest extinction;
C min is the concentration of K or Na in mg, corresponding to the smallest extinction,
And with a K content of <29.5 mmol / L and Na <22.6 mmol / l, microvascular angina is diagnosed in IHD patients.
print version
Date of publication 05.04.2007gg
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