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Determination of genesis and localization of ventricular ectopic focus in a patient with coronary artery disease
Abstract
To determine the origin and localization of ventricular arrhythmia in a patient with an ischemic heart disease coronary artery disease a comprehensive examination was carried out, which allowed defining the cause of the arrhythmia and selecting a successful therapy. We tried to reveal the importance of finding the causes of high gradation ventricular arrhythmias in the patient with coronary artery desease having survived acute myocardial infarction and having systolic dysfunction. The preceding treatment with beta-blockers and amiodarone was not effective. Due to the comprehensive examination, including psychological questionnaires, the realization of mental tests and exercises stress tests for the ventricular arrhythmias provocation as well as topical diagnostics of the focus localization of ventricular automaticity it was possible to make a correct diagnosis, select precise therapy and to avoid expensive and unnecessary in this case treatment such as implantable cardioverter defibrillator installation.
... В продолжение рассмотрения провоцирующих факторов нельзя не упомянуть о давно известных «психогенных аритмиях» [27][28][29]. Есть сообщения о том, что психологические и психосоциальные факторы зачастую являются триггерами в развитии ЖА, проявлением какой бы нозологической формы они ни являлись [30,31]. Сильные эмоции (как отрицательные, так и положительные) могут привести к ВСС у пациентов с ИБС, что было объективизировано результатами исследования по изучению электрограмм имплантированного кардиовертера-дефибриллятора пациентов, которые пережили нападение на Всемирный торговый центр в Нью-Йорке в 2001 г. ...
... а -в покое, б -пациент остановился из-за боли, в -продолжил ФН через 2 мин после приема Ng. пациента на ментальные пробы/психодиагностику для подтверждения такой закономерности [30]. ...
... При мониторировании ЭКГ более 5-7 сут было замечено, что максимальное количество ЖЭК часто наблюдалось в первые дни ММ [47]. У пациентов с ИБС при мониторировании ЭКГ вариативность ЖА косвенно может указывать на изменения обстоятельств, в частности на психогенный характер нарушений ритма, увеличение/ уменьшение физической активности [30,48]. ...
According to the analysis of literature data on the management of patients with coronary artery disease and ventricular arrhythmias was developed unified ventricular arrhythmia profile and proposed combined conclusion on Holter monitoring based on it, including clinical and electrocardiographic characteristics ventricular arrhythmias that will help to determine the management of a patients faster.
... При психогенной природе ЖА у пациентов со стабильной ИБС к терапии может быть добавлен психотропный препарат и/или использована психотерапия. Так, описаны случаи эффективного лечения ЖА, резистентных к другим методам лечения, включая РЧА, с помощью психокоррекции [61]. Следует заметить, что устранение расстройств психологического статуса (дистресса, тревожности, депрессии) должно рассматриваться и с позиции максимальной коррекции факторов сердечно-сосудистого риска. ...
... В случаях, когда ЖА у больного с ПИКС во время ХМ регистрируются равномерно в течение суток и не имеют динамики в ходе нагрузочных тестов, РЧА является предпочтительным методом лечения этих аритмий [36]. Это можно объяснить тем, что при стабильной ИБС участки миокарда неоднородны по своим электрофизиологическим свойствам вследствие рубцовых изменений или диффузного кардиосклероза, что предрасполагает к аритмогенезу и без воздействия триггерных факторов [30,61,36]. ...
... При психогенной природе ЖА у пациентов со стабильной ИБС к терапии может быть добавлен психотропный препарат и/или использована психотерапия. Так, описаны случаи эффективного лечения ЖА, резистентных к другим методам лечения, включая РЧА, с помощью психокоррекции [81]. Следует заметить, что устранение расстройств психологического статуса (дистресса, тревожности, депрессии) должно рассматриваться и с позиции максимальной коррекции факторов риска развития сердечно-сосудистых осложнений. ...
... В случаях, когда ЖА у больного с ПИКС во время ХМ регистрируются равномерно в течение суток и не имеют динамики в ходе нагрузочных тестов, РЧА является предпочтительным методом лечения [83]. Это можно объяснить тем, что при стабильной ИБС участки миокарда неоднородны по своим электрофизиологическим свойствам вследствие рубцовых изменений или диффузного кардиосклероза, что предрасполагает к аритмогенезу и без воздействия пусковых факторов [39,81,83]. ...
The paper gives an original algorithm for the management of patients with stable coronary artery disease, preserved/moderately reduced left ventricular systolic function, and high-grade ventricular arrhythmias from the first registration of the latter to the choice of treatment policy. Great attention is paid to the assessment of a private clinical case, by determining the nature of arrhythmias, and to the involvement of autonomic regulation in the genesis of ventricular arrhythmias. The importance of topical diagnosis of ventricular arrhythmias and identification of psychological disorders is emphasized. Diagnostic problems are solved in a step-by-step fashion using up-To-date techniques. The key point of the algorithm proposed is to prevent sudden cardiac death.
... Registration and analysis of unipolar electrocardiograms from multiple leads on the surface of the chest (body surface potential mapping [BSPM] method) have high sensitivity and help to obtain detailed information about electrophysiological processes (Mirvis 1988;De Ambroggi and Corlan, 2011;Polyakova et al., 2015;Strutynsky et al., 2015;Wissner et al., 2017). The information obtained using this method includes the amplitude, temporal, and spatial components of the signal, and it is used to localize and evaluate the area of ischemic damage of the heart muscle, myocardial electrical inhomogeneity and its hypertrophic remodeling (Magomedova et al., 2016;Tsyganov et al., 2018) and to diagnose cardiac arrhythmias, cardiomyopathies, and myocardial hypertrophy (Bond et al., 2013;Treshkur et al., 2014;Srinivasan et al., 2019). ...
Ivonina, Natalya I., Andrey A. Fokin, and Irina M. Roshchevskaya. Body surface potential mapping during heart ventricular repolarization in male swimmers and untrained persons under hypoxic and hypercapnic hypoxia. High Alt Med Biol. 00:000-000, 2021. Background: In swimmers, as a result of prolonged breath-holding during swimming, first hypoxic hypoxia (HH) and then hypercapnic hypoxia (HCH) occurs, which may influence the electrical activity of the heart (EAH). What type of normobaric hypoxia more strongly affects the EAH-normocapnic HH or HCH? Methods: The electrical activity of swimmers' hearts (n = 7) and untrained persons (n = 10) was studied by using electrocardiography (ECG) and body surface potential mapping (BSPM) during the period of ventricular repolarization at baseline, at normocapnic HH, at HCH, and in the recovery period. Results: HH led to more significant changes in the EAH in all participants in comparison with HCH. There was no change in the amplitude of T waveECG at hypoxic and HCH, but a change in the amplitude of the minimum was noted in BSPM. The minimum in athletes changed by the end of the exposure (from -0.40 ± 0.12 mV to -0.26 ± 0.11 mV, p = 0.001); in the control, it decreased earlier (after 8 minutes of exposure to HH, the amplitude of the minimum was -0.24 ± 0.08 mV, p = 0.026). With HH, the duration of the QT interval in athletes was shortened due to the shortening of the J-Tpeak (from 250 to 188 ms, p = 0.001) and the Tpeak-Tend (from 98 to 86 ms) intervals. In controls, the decrease in the QT interval was due to the J-Tpeak shortening only (from 280 to 200 ms, p = 0.026). Conclusions: In the study of the effect of hypoxia on the EAH during ventricular repolarization, the use of the BSPM has proven to be more informative than the use of traditional ECG. When using potential mapping, more significant changes in ventricular repolarization at HH than at HCH were revealed, whereas the parameters changed less in swimmers compared with the baseline than in controls during both exposures.
... Доказано участие психоэмоционального фактора в аритмогенезе некоронарогенных ЖА, и приводятся убедительные данные, что патогенетическое лечение анксиолитиками тревожных невротических расстройств (ТНР), ассоциированных с ЖА, не требует применения АА-средств [8][9][10][11]. Причем это справедливо для больных как с идиопатическими формами аритмии, так и с серьезной сердечно-сосудистой патологией [12]. ...
... Заметим, что при оценке результатов ХМ и нагрузочных проб, очень важна такая характеристика как воспроизводимость аритмических событий, которая должна отражаться во врачебном заключении наряду с другими показателями (количество и комплексность ЖА, частота сердечных сокращений (ЧСС), артериальное давление (АД), время появления значимой депрессии ST и/или ангинозных болей, толерантность к ФН и т. д.). Более того, в своих работах мы показали, что отношение врача к ЖА у больного стабильной ИБС во многом зависит от итогов нагрузочных проб [5,8,9]. Оценка «поведения» ЖА во время ФН очень важна, так как результаты его могут быть различны даже при положительной нагрузочной пробе. ...
A clinical case of a 56-year-old man is presented in which only ventricular tachycardia without clinical and ECG criteria of myocardial ischemia is recorded on the exercise test. The ventricular tachycardia was the only reason for stopping the test. This clinical case demonstrates all the difficulties in determining the genesis of ventricular arrhythmias induced by exercise. The purpose of the work was to show all the difficulties in determining the genesis of exercise-induced ventricular arrhythmia. The literature references related to the exercise-induced ventricular arrhythmia differentiation is rather poor. It is only known that if a patient develops and progresses ventricular arrhythmia, a tredmill test is considered questionable. Exerciseinduced ventricular arrhythmias especially ventricular tachycardia, are the most dangerous. Therefore, additional diagnostic methods were used to reveal the main disease as the background of ventricular tachycardia. Results of pharmacological test with nitroglycerine were the indication of the ischemic origin of ventricular tachycardia. Coronary angiography did not reveal coronary artery stenoses. Positron emission tomography revealed coronary microcirculation disturbance after which a decision about metabolic therapy with Mexicor was made. The correct choice of the drug (Mеxisor) was confirmed by the results of control studies — improvement of metabolism and antiarrhythmic effect. The article concludes that the choice of the treatment exercise-induced ventricular arrhythmia in patients with stable coronary artery disease should be individual and pathogenetic.
... Поиск неишемических причин желудочковой эктопии выявил, что психологический стресс может выступать как в качестве первопричины, так и триггера ВСС [14,15]. Есть сообщения о применении психокоррекции, в частности, приводится клинический случай успешного лечения ЖА высоких градаций психогенного происхождения у пациента с перенесенным ИМ без применения антиаритмических препаратов [16]. ...
It is known that ventricular dysrhythmias in patients with ischemic heart diasease can be of various origin. Hence selection of antiarrhythmic tactics in such patients should be individual and pathogenetically proved. Aim. To check antiarrhythmic abilities of metabolic therapy for ischemic heart disease combined with variety of ventricular arrhythmias of III-IV grades (by Myerburg RJ). Material and methods. for 42 patients with ventricular arrhythmias of high grade and stable ischemic heart disease with saved ejection fraction of the left ventricle, before and after treatment were done the following: Holter monitoring, treadmill test, and as indicated — coronary arteriography, radionuclide methods of perfusion assessment and metabolism of myocardium, non-invasive topical diagnostics. To individually selected antianginal and antihypertension therapy for all patients was added ethylmethylhydroxypyridine succinate (es) in daily dosage 300 mg, for 2 months. Results. During the study, according to relationship of ventricular arrhythmia with transient ischemia, patients were selected to 2 groups. In the 1 group, with ischemic arrhythmias, in 2 months after start of es, there was significant antiarrhythmic effect: number of single ventricular premature beats decreased by 55%, couplets — by 90%, and episodes of non-sustained ventricular tachicardia — by 100%. At control positrone-emisson tomography in the areas of myocardial ischemia there was significant increase of 11C-buthirate sodium excretion, which witness on the increase of efficacy of energetic metabolism in zones of hypoxia. In the II group, with non-ischemic ventricular arrhythmias — antiarrhythmic effect was not achieved. Conclusion. es should be regarded as pathogenetic chain in complex antiarrhythmic treatment of ventricular arrhythmias in patients with stable ischemic heart disease.
... Поиск неишемических причин желудочковой эктопии выявил, что психологический стресс может выступать как в качестве первопричины, так и триггера ВСС [14,15]. Есть сообщения о применении психокоррекции, в частности, приводится клинический случай успешного лечения ЖА высоких градаций психогенного происхождения у пациента с перенесенным ИМ без применения антиаритмических препаратов [16]. ...
Aim. To assess somatic comorbidity in male and female cohort with stable angina (sA). Material and methods. Into multicenter, simlutaneous cohort-clinical study, 300 men included (mean age 54±0,4 y.o.) and 230 women (mean age 55,7±0,5 y.o.) with sA of I-III functional class. four institutions participated from Ingushetia Republic. Clinical and instrumental assessment included anthropometry, office blood pressure, heart rate, eCG in 12 leads recording. In fasting venous blood we measured total cholesterol (mM/L) and glucose (mM/L).Results. In cohort of patients with sA the most prevalent are cholelythiasis, gastric and duodenal ulcer disease, chronic diseases of pancreas, separately or together; chronic bulbitis is found in each third person, and urinary lythiasis in 15% of cases. Gastric ulcer and duodenal ulcer diseases, chronic bronchitis and urinary lythiasis are two times more prevalent in men compare to women, but cholelythiasis and chronic diseases of pancreas show the same prevalence among men and women.Among women with sA thyroid diseases are 3 times more prevalent than in men.Conclusion. so, in sA patients comorbidity is quite common. Management and prevention in sA patients cohort should be multifactorial taken a broad spectrum of social and demographic parameters, main risk factors and comorbidities. The key role in coordination and realization of all these activities should be granted to an internist of broad spectrum or general care physician.
Although anecdotal evidence has long suggested links between emotion and ventricular arrhythmia, more recent studies have prospectively demonstrated the arrhythmogenic effects of anger, as well as mechanisms underlying these effects.
Epidemiological studies reveal that psychological stress increases sudden death, as well as arrhythmias, in patients with implantable cardioverter-defibrillators, in populations during emotionally devastating disasters such as earthquake or war. Diary-based studies confirm that anger and other negative emotions can trigger potentially lethal ventricular arrhythmias. Anger alters electrophysiological properties of the myocardium, including T-wave alternans, a measure of heterogeneity of repolarization, suggesting one mechanistic link between emotion and arrhythmia. Pilot studies of behavioral interventions have shown promise in decreasing arrhythmias in patients with implantable cardioverter-defibrillators.
Anger and other strong emotions can trigger polymorphic, potentially life-threatening ventricular arrhythmias in vulnerable patients. Through autonomic changes including increased sympathetic activity and vagal withdrawal, anger leads to increases in heterogeneity of repolarization as measured by T-wave alternans, known to be associated with arrhythmogenesis, as well as increasing inducibility of arrhythmia. Further delineation of mechanisms linking anger and arrhythmia, and of approaches to decrease the detrimental effects of anger and other negative emotions on arrhythmogenesis, are important areas of future investigation.
The effect of coronary artery bypass grafting (CABG) on exercise-induced ventricular arrhythmias was examined in 53 patients. A bicycle exercise test and an isometric handgrip exercise test were performed before and 3 months after CABG. Exercise-induced ventricular arrhythmias were detected preoperatively in 14 patients (26%), in 13 during the bicycle test and in 11 during the handgrip test, and in 18 patients (34%) after CABG. Thus, CABG had no significant effect on the occurrence of exercise-induced ventricular arrhythmias. Nine patients had new exercise-induced ventricular arrhythmias after CABG, 8 of whom had evidence of previous myocardial infarction, whereas only 8 of the 35 patients (23%) without postoperative ventricular arrhythmias had had a previous infarction. The rate of graft patency or improvement in exercise tolerance in patients with new postoperative arrhythmias did not differ from that in patients who did not have exercise-induced arrhythmias after CABG. The results confirm that CABG has no influence on the occurrence of ventricular arrhythmias induced by physical exercise. Patients with a previous myocardial infarction appear to be prone to new ventricular arrhythmias despite successful revascularization.