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GENDER FEATURES OF EARLY STENOTIC LESIONS OF CORONARY
ARTERIES IN HIGH-RISK PATIENTS WITH THE PRESENCE OF
MULTIFOCAL ATHEROSCLEROSIS
Rustamov Zoxidjon Vaxidjon o'g'li
Karimova Xurliqo Elmurodovna
Azimova Aziza Azimovna
Samarkand State Medical University
https://doi.org/10.5281/zenodo.13827855
Аннотация:
The aim of the study
was to identify individuals with increased
frequency of early symptoms of stenosing atherosclerosis of the coronary arteries with
consideration of the peculiarities of comorbid abnormalities in CHD patients high risk with the
presence of MFA.
Keywords:
comorbid burden, ischemic heart disease, acute coronary syndrome,
myocardial infarction, angina pectoris, cerebrovascular disease, acute and chronic cerebral
circulation disorders, arterial hypertension, intermittent claudication, chronic arterial ischemia of the
lower extremities
INTRODUCTION
Multifocal atherosclerosis (MFA) as a systemic disease prone to continuous
progression regardless of localization, hemodynamically significant lesion of several
vascular basins, determining the severity of the disease [1], has an unfavorable
prognosis of clinical events [2], as well as a high frequency of incidence of ischemic
heart disease (IHD) [3-5]. There is a data of the negative effect of MFA on the remote
prognosis in the group of patients with stable coronary artery disease and in acute
coronary syndrome (ACS). About the half of patients with MFAs with vascular
comorbid burdening die mainly from myocardial infarction (MI) and stroke within 7
years after the diagnosis has been established
However, in the literature there are no uniform generally accepted criteria for
assessing the level of stenosis, which are subject to accounting and the description of
methods for their assessment [7], as well as segmental features of coronary vascular
lesions in men and women of MFAs of the middle age category [8, 9]. The gender gap in
the risk of IHD persists throughout life, but the relative risk decreases with the age [8–
11]. In recent years, the early development of IHD in women [12, 13] has been
accompanied by a more favorable clinical course, and in men, on the contrary, for that,
who younger than 60 years, the risk of coronary course is higher [10, 14].
Based on these conclusions, to solve the problems of identifying the nature of
coronary vascular lesions in middle-aged men and women, we conducted research to
identify individuals with an increased incidence of signs of stenotic atherosclerosis,
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taking into account the clinical symptomatology and features of vascular comorbid
aggravation in patients with IHD of high-risk with the presence of MFA.
MATERIALS AND METHODS
The study involved 1637 patients who were hospitalized at the Regional Vascular
Center No. 1 on the basis of the “Emergency Hospital” of the city of Ufa in the period from 2010
to 2017, of which 288 people of middle age were selected with the presence of MFA. Depending
on the predominant lesion of the vascular basin, patients were divided into 3 clusters according
to the clinical manifestations of atherosclerotic heart failure (1st cluster – 96 people), head brain
(2nd cluster – 96 people) and lower limb arteries (3rd cluster – 96 people), confirmed by
coronary angiography (CAG), by ultrasound doppleroscopy (UZDS) of the trunk arteries of the
head (MAH) and lower extremities. The average age of patients of the 1st cluster was
50.06±8.49 years, the 2nd cluster – 48.42±9.86 years, the 3rd cluster – 55.06±4.11 years.
The coronary angiography was got by the 288 examined patients with MFA who
had acute myocardial infarction, as well as with the clinic for acute coronary syndrome
(ACS), vasospastic, unstable and progressive angina pectoris with the predominant use of
transfemoral access on the digital monoplanar universal angiographic installation named
"Innova 3100". According to the National Clinical Recommendations for Stable Angina
2011, damage to the coronary arteries (CA)> 50% were considered significant, and <50% –
hemodynamically insignificant [15]. And also guided by the clinical recommendations of
the European Society of Cardiology for the management of acute myocardial infarction
patients with ST segment elevation from 2017, the lesion from 50 to 75% was considered as
borderline, from 76 to 90% – hemodynamically significant or subcritical [16].
In all patients, the clinical feature of the lesion of the arterial basins was determined taking
into account the previous acute myocardial infarction (AMI), stable, unstable, progressive,
vasospastic angina pectoris, acute and chronic cerebral circulation disorders (OCCD, CCCD), a
chronic arterial ischemia of lower limbs (CAILL) of the middle age category, which were
also held echocardiography (ECHO-KG). During the hospitalization of patients in our
center, according to indications, magnetic resonance imaging of the chest and abdominal
organs (MRI of CO, MRI of AO), ultrasound of abdominal organs and kidneys, and if
necessary, pelvic ultrasound were performed. The study was conducted in accordance with
the Helsinki Declaration and approved by the Ethics Committee of FSBEI HE "BSMU". Informed
agreement was obtained from each patient.
Statistical processing of the obtained data was carried out using the methods of variation
statistics using the IBM SPSS Statistics 22 software package for determining the kind of
distribution; the Shapiro-Wilk criterion was used. When comparing more than two groups
according to qualitative and quantitative characteristics, the Kruskel-Wallis method of
rank analysis was used. The Wilcoxon test was used to compare two related samples
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by quantitative characteristics with a distribution other than normal. The combination of
the values of categorical variables was implemented using a hierarchical algorithm of
the three-cluster model using the χ2 criterion. Based on dendrograms, diagrams and
numerical characteristics, the clinical and instrumental data were stratified into MFA
clusters with the determination of their number and the percentage calculation. The
statistical significance of the differences was determined at a significance level of p<0.05.
RESULTS AND DISCUSSION
As a result of the analysis of the data which was made, in patients entering into the high-risk
group (Table 1), the incidence of stage III arterial hypertension (AH III) in the 1st cluster was
high and amounted to 95.8%, in 2nd – 66.7% (p1–2=0.0012). The stroke in a history in patients
of the 2nd cluster was determined in 52.1% of cases, in patients of the 3rd cluster – in 10.4%, in
the 1st cluster – in 8.3% (p2–1.3= 0. 0000). The intermittent claudication was detected in patients
of the 3rd cluster in 78.1%, 2-nd – 40.6% and 1-st – 33.3% (p 3–1.2=0.0000).
All men of the 1st cluster (n = 48) were combined with the arterial hypertension of the stage
III, in 54.2% with unstable angina, in Table 2. The frequency of lesion of the segments of the right
coronary artery in patients with MFA of the middle age category 68.7% with MI in anamnesis.
Among male patients of 1st cluster who had an acute myocardial infarction, ST segment
elevation was detected in 36.4% of patients examined in combination with atrial fibrillation
(21.2%), atherocalcinosis of aorta and its branches (15.2%).
Under the dynamic observation of patients of the 2nd cluster the arterial hypertension
of the III stage were found in 66.7% of patients which was combined with stable angina of the
2nd FC in 43.7% of cases, and also in 30.2% with left ventricular hypertrophy (LVH) at the same
time, a rather high level of transferred stroke in anamnesis was noted – 52.1%. Acute
cerebrovascular deceases (ACVA) at the time of inspection were found in 43.7% of patients,
among them ischemic stroke was detected in 38.5%, intracerebral hemorrhage – in 18.7% of
cases. Hemorrhagic stroke in 11.5% of those surveyed developed as a result of MBA
aneurysm. Transferred cerebral ischemic seizures were diagnosed in 21.2% of patients; the
late recovery period of ACVA is in 11.5%.
Analysis of the clinical symptoms and functional parameters of patients of the 3rd cluster
revealed the presence of ACS in 50% of women, the prevalence of grade II hypertension in men
with fourth risk (58.3%), stable angina pectoris with FC2 (64.6%), early onset of CEH without
transferred stroke in anamnesis (77.1%). Among men and women, intermittent claudication
was established in 79.2% of patients, while a functional ECG study revealed a spontaneous ST
segment decline in 20.8% of the examined individuals, LVH – in 17.7%, the ventricular
extrasystoles in combination with cicatricial changes in LV in 20.8%. Analysis of the
frequency and extent (Table 2) of the stenosing lesion of the 2 RCA segment showed that in
patients of middle age group hemodynamically insignificant stenosis (degree of stenosis
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<50%) was more frequent, prevailing in women of the 1st cluster – 81.3% = 0.0201) and men
of the 3rd cluster – 70.8% (P1–2= 0.0309). The nature of stenosing lesions of the 3rd segment of
RKA also had a predominant narrowing of <50% in women of the 1st cluster – 95.8% (P2–1=
0.0135) and men of the 3rd cluster – 100% (P1–2= 0, 0000), which indicated a tendency for the
subclinical lesion of RKA to be more pronounced with the presence of stable angina pectoris in
women of the 1st cluster in 35.4% of cases and men of the 3rd cluster in 33.3% of cases (Table
3). Stable angina according to our data did not manifest itself for a long time. With an increase
in the narrowing of the arteries in diameter from 45 to 50%, the patients showed short-term
attacks of angina pectoris — the presence of chest pain.
Hemodynamically significant stenoses of PKA (76-90%) were found in patients with 1
and 3 clusters. In a comparative analysis of lesions of the 2nd segment of RKA, no significant
differences in men and women were obtained. Among women, a significant change was the
primary lesion of the third PKA segment in 50% of patients with acute coronary syndrome
(ACS), belonging to the 3rd cluster examined in accordance with a single center study (P2–
1=0.0000).
Comparative characteristics of the lesion of the branches of the left coronary artery
(LCA) showed (Table 4) the prevalence in women of hemodynamically insignificant stenoses
(<50%) of the 6th segment of the PMRA, detected in 93.8% of the examined of the 1st cluster
(P2-1 = 0.0000) , also in 100% of patients of the 3rd cluster (P2-1 = 0.0223). When the
degree of stenosis of the diagonal branch (DB) is less than 50% among patients belonging to
the 1st cluster, were registered in 100% of women (P2-1 = 0.0105), combined with
vasospastic angina in 27.1% of cases and
Table 3. The frequency of the occurring different forms of angina pectoris in men and women with
MFA of the middle age category
Table 4. The frequency of lesions of the branches and segments of the left coronary artery in
men and women of the middle age category with MFA
for the first time arising angina pectoris in 20.8% of cases (table 3). A hemodynamically
insignificant change in the 15th segment of the circumflex artery (CA) was a significant
predominance of women of the 1st cluster – 81.3% (Р2-1= 0.0000), and also a men of the 3rd
cluster – 70.8% (Р1-2=0.0171).
The frequency of incidence of borderline stenosis (50-75%) of the LCA branches showed
the prevalence of men of the 1st cluster with a lesion of the 6th segment of the PMRA in
25.0% (P1-2= 0.0063), with DB involvement in 20.8% (P1-2= 0.0152), as well as 15 CA
segment in 31.3% (P1-2 = 0.0000), accompanied by the presence of stable angina in 41.6% of
cases (Table 4). At the same time, borderline numbers of stenosis of the 6th segment of PMRA
were obtained in 29.2% of men with the 3rd cluster (Р1-2= 0.0002) and in 10.4% of women with
the 2nd cluster (Р2-1= 0.0366). The majority of patients with hemodynamically
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significant changes in the branches of LCA (76-90%) belonged to the 1st cluster with
damage of the 6th segment of PMRA in 22.9% of men (P1-2= 0.0105), DB at the 20.8% of
men (P1-2= 0.0149),
15 segment of CA at 27.1% of men (P1-2= 0.0359), wherein, unstable angina
pectoris is established in 54.2% of men (Table 4). A subtotal narrowing of the 6th segment of
the PMRA from 76 to 90% was also observed in 14.5% of middle-aged men with the 2nd
cluster (Р1-2 = 0.0332). Among women, there was a reliable hemodynamically significant
narrowing only among the examined 3rd cluster with a lesion of the 15th segment of СA,
established in 50% of patients with ACS (Р2-1 = 0.0228).
CONCLUSION
The nature of the lesion of the coronary vessels in men and women of the middle
age group revealed individuals with an increased frequency of signs of stenotic
remodeling, taking into account the clinical symptomatics and features of vascular
comorbid aggravation in high-risk coronary heart disease patients with the presence of
MFA.
One of the manifestations of ischemic heart disease was ACS with hemodynamically
significant stenosis of PKA (76-90%), which developed in 50% of women with a primary
lesion of the 3rd segment of PKA, belonging to the 3rd cluster of the patients. In the structure of
hemodynamically significant changes in the branches of LKA, were prevailed men of the 1st
cluster with a lesion of the 6th segment of the PMRA, DB, 15th segment of CA, while unstable
angina pectoris was found in 54.2% of them, MI in the anamnesis – in 51.1%. Among male
patients of 1st cluster who had an acute myocardial infarction, ST segment elevation was
detected in 36.4% of patients examined in combination with atrial fibrillation (21.2%), the
atherocalcinosis of the aortic and its branches (15.2%).
The frequency of meeting of borderline stenosis (50-75%) of the LKA branches
showed the predominance of men of the 1st cluster with damage of the 6th segment of the
PMRA, with the involvement of DB, as well as 15 segments of CA, accompanied by a clinic
of stable angina pectoris. Analysis of the frequency and degree of stenosing lesions of the
PKA segments showed that hemodynamically insignificant stenoses (degree of stenosis
<50%), which prevailed in women of the 1st cluster and men of the 3rd cluster, were more
common in patients, that indicating a tendency for their subclinical lesions of PKA with the
presence of stable angina, which according to our data for a long time did not manifest itself.
With an increase in the narrowing of the arteries in the diameter from 45 to 50%, at the
patients showed short-term attacks of angina pectoris.
Comparative characteristics of the lesion of the branches of the left coronary artery
showed the prevalence in women of hemodynamically insignificant stenoses (<50%) of the
6th segment of the PMRA, detected mainly in the 1st cluster examined and also in patients of
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the 3rd cluster. With the degree of stenosis of the diagonal branch (DB) less than 50%
among patients belonging to the 1st cluster, were registered at all women, combined with
vasospastic angina in 27.1% of cases and for the first time developed angina pectoris
in 20.8% of cases.
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