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ID naloge: 92 Letnik: 2000 Predmet: interna medicina
Pomen klinicnih in histoloških dejavnikov pri nastanku rupture proste stene po akutnem srcnem infarktu
Avtor: Mojca Hajdinjak, Robert Hajdinjak
Mentor: doc. Dr. Dušan Štajer
Somentor: doc. Dr. Nina Zidar
Uvod. Ruptura proste stene (RPS) je mehanicni zaplet akutnega srcnega infarkta (ASI), ki se praviloma konca s smrtjo in je vzrok za 5 - 24% smrtnih primerov pri ASI. Zdravljenje RPS je vecinoma neuspešno. Smrtnost zaradi RPS bi lahko zmanjšali predvsem s preprecevanjem RPS, pri cemer bi nam pomagalo boljše poznavanje dejavnikov tveganja in mehanizmov za nastanek RPS.
Namen naloge. Sklepali smo, da so nekateri lahko dostopni klinicni dejavniki pri bolnikih z ASI povezani z nastankom RPS in da lahko na podlagi teh dejavnikov napovedujemo tveganje za RPS pri bolnikih z ASI. Menili smo tudi, da obstajajo histološke razlike v srcni mišici med bolniki z RPS in bolniki, ki so umrli z ASI iz drugih vzrokov.
Bolniki in metode dela. V retrospektivno študijo smo zajeli vse bolnike z RPS, ki so se zdravili zaradi ASI v Centru za intenzivno interno medicino v obdobju med 1. 1. 1990 in 31. 12. 1999, pri katerih je bila RPS potrjena z obdukcijo ali z ultrazvocno preiskavo srca. Kontrolno skupino so predstavljali nakljucno izbrani bolniki z ASI iz istega obdobja. Preucevali smo povezavo med pojavljanjem RPS in starostjo, ženskim spolom, prisotnostjo arterijske hipertenzije, sladkorne bolezni, že prebolelega infarkta in mestom ASI. S pomocjo logisticne regresije smo izdelali model za napovedovanje RPS pri bolnikih z ASI.
V histološko analizo smo vkljucili avtopsijske vzorce srca 25 bolnikov z RPS po ASI in kot kontrolno skupino avtopsijske vzorce srca 25 umrlih bolnikov z ASI, pri katerih ni prišlo do RPS. Bolnike smo razdelili še v 3 podskupine glede na starost ASI in primerjali histološke spremembe med bolniki z in brez RPS pri ASI starim <1 dan, 1 do 4 dni in >4 dni.
Rezultati. Vkljucili smo 132 bolnikov z RPS in 132 kontrolnih bolnikov. Z nastankom RPS so bili v naši raziskavi povezani višja starost bolnika (p<10?6, t-test), ženski spol (p<10-6, C2 test), arterijska hipertenzija (p=10-3, C2 test), sladkorna bolezen (p=10-3, C2 test) ter infarkt spodnje stene levega prekata (p=10-4, C2 test). Z metodo logisticne regresije smo izdelali enacbo, s katero je možno na podlagi klinicnih podatkov napovedati tveganje za RPS pri vkljucenih bolnikih z ASI.
Pri bolnikih z ASI starim <1 dan in >4 dni nismo opazili razlik v histoloških spremembah v srcni mišici med bolniki z RPS in umrlimi bolniki brez RPS. Pri bolnikih z ASI starim 1 do 4 dni pa smo v intersticiju bolnikov z RPS našli intenzivnejšo infiltracijo z nevtrofilnimi granulociti (p<0,05, Fisherjev test).
Zakljucek. Nastanek RPS bi pri bolnikih z ASI lahko napovedovali iz dostopnih klinicnih podatkov o starosti, spolu, povišanem krvnemu tlaku, sladkorni bolezni in mestu srcnega infarkta. Vecja gostota granulocitne infiltracije infarktnega podrocja pri bolnikih z RPS ima lahko pomembno vlogo pri slabitvi stene srca in nastanku RPS.
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[Abstract / English version]
Importance of clinical and histological factors in the
development of rupture of free ventricular wall after acute myocardial infarction
Author: Mojca Hajdinjak, Robert Hajdinjak
Mentor: doc. Dr. Dušan Štajer
Co-mentor: doc. Dr. Nina Zidar
Background. Rupture of the free ventricular wall (FWR) is a serious and mostly lethal mechanical complication of acute myocardial infarction (AMI) that causes 5-24 % of all infarct-associated deaths. Treatment of FWR is rarely successful. Mortality of FWR could be reduced by prevention of FWR. Better knowledge of risk factors and mechanisms of development of FWR would be useful in prevention of FWR.
Objectives. Our hypothesis was that in patients with AMI, simple clinical factors are predictive of FWR and could be used for the assessment of the risk for FWR. We also assumed that there is a difference in histological changes in infarcted myocardium between patients who died of FWR and patients with AMI who died of other causes.
Methods. Patients with AMI who developed FWR, treated in the Centre for Intensive Internal Medicine between 1. 1. 1990 and 31. 12. 1999, were included. FWR was confirmed with echocardiography and/or autopsy in all patients. The control group consisted of randomly selected patients with AMI not complicated by FWR. We studied the correlation between the incidence of FWR and age, female gender, history of systemic hypertension, diabetes mellitus, previous AMI and location of AMI. The selected patients were used in a logistic regression model for calculation of the risk of FWR in patients with AMI.
In the histologic part of the study we analysed autopsy samples of heart tissue from 25 patients with FWR and from the control group of 25 patients with AMI without FWR. Both groups of patients were split into 3 groups with regard to the age of AMI. The histological changes between patients with and without FWR were compared in AMI <1 day old, 1 to 4 days old and >4 days old.
Results. We included 132 patients with FWR and 132 control patients. Advanced age (p<10-6, t-test), female gender (p<10-6, C2 test), history of systemic hypertension (p=10-3, C2 test), diabetes mellitus (p=10-3, C2 test) and AMI of the inferior left ventricular wall (p=10-4, C2 test) were factors associated with FWR. Using the logistic regression we obtained a formula for prediction of FWR in patients with AMI included in the study.
In patients with AMI <1 day old and >4 days old there were no differences in histological changes between patients with FWR and patients without FWR. Patients with 1 to 4 days old AMI and FWR had a significantly more intensive neutrophil infiltration than patients without FWR (p<0,05, Fisher's test).
Conclusions. The risk of FWR in patients with AMI can be predicted from clinical data. Greater density of granulocytes in the 1 to 4 days old infracted tissue of patients who developed FWR may have an important role in the development of FWR.
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