Nghiên cứu biểu hiện lâm sàng, điện tim, siêu âm tim và kết quả chụp cắt lớp vi tính đa dãy động mạch vành ở bệnh nhân bệnh phổi tắc nghẽn mạn tính tt tiếng anh

1 EXECUTIVE SUMMARY Chronic obstructive pulmonary disease is the fourth leading cause of death in the world after heart disease, cancer and brain stroke Although chronic obstructive pulmonary disease predominantly affects the lungs, it also causes or is associated with many systemic conditions, especially cardiovascular disease The effects of cardiovascular disease caused by chronic obstructive pulmonary disease and the combination of cardiovascular disease with chronic obstructive pulmonary disease further increase the severity of the disease, increase complications, increase mortality ratios; and coronary artery disease is the leading cause of death from cardiovascular disease The introduction of coronary computer tomography (Computer Tomography-CT) is considered as a solution for the diagnosis of coronary artery lesions There are a number of studies on chronic obstructive pulmonary disease in Vietnam, covering many aspects of the disease in patients with chronic obstructive pulmonary disease but no specific and detailed research is available Coronary lesion points in patients with chronic obstructive pulmonary disease Therefore, continuing to study the characteristics of cardiovascular disease in patients with chronic obstructive pulmonary disease, especially the study of coronary artery damage on computerized tomography in high-risk groups and is related to some clinical features of chronic obstructive pulmonary disease which is necessary, with scientific and practical significance necessary to improve the understanding of the relationship between them contributing to the prognosis, improving the effectiveness of the treatment treatment and mortality reduction We conduct research on the subject: "The study of clinical manifestations, ECG, echocardiography and results of coronary artery computed tomography in patients with chronic obstructive pulmonary disease" The objective of the topic: 1.1 Describe clinical features, ECG, echocardiography of some cardiovascular diseases in patients with chronic obstructive pulmonary disease 1.2 Evaluation of the results of computerized tomography of coronary artery multilayer in patients with chronic obstructive pulmonary disease with high cardiovascular risk and related with some clinical, subclinical characteristics of obstructive pulmonary disease chronic New contributions of the thesis - Describes the clinical features, ECG, echocardiogram of some cardiovascular diseases in patients with chronic obstructive pulmonary disease - Evaluates the results of computerized tomography of coronary artery series and its relationship with clinical and subclinical patients with chronic obstructive pulmonary disease The thesis structure The thesis consists of 126 pages, with chapters: Introduction 02 pages, Chapter 1- Overview: 37 pages, Chapter 2- Objects and research methods: 24 pages, Chapter 3- Results: 34 pages, Chapter Discussion: 28 pages Conclusions and recommendations: 03 pages The thesis has 36 tables, 15 pictures, 05 charts, 05 graphs, 03 diagrams, 131 references: 51 Vietnamese, French and 79 English Chapter OVERVIEW 1.1 CHRONIC OBSTRUCTIVE PULMONARY DISEASE According to BOLD (The Burden of Obstructive Lung Disease) and other major epidemiological studies, there were an estimated 385 million cases of chronic obstructive pulmonary disease in 2010, with the prevalence in the world is 11.7% Globally, there are about million deaths annually With the increase in smoking rates in developing countries and the aging population in high-income countries, the incidence of chronic obstructive pulmonary disease is expected to increase over the next 30 years and until next year 2030 there could be up to 4.5 million deaths annually from chronic obstructive pulmonary disease and related conditions Classification of severity of chronic obstructive pulmonary disease based on FEV1 after bronchodilator remedy (GOLD 2016) In patients with FEV1 / FVC index 90times / minute) Breathing> 20 times / minute Increase of blood pressure Systolic blowing 3-valve valve T2 strong, split valve pulmonary artery Hartzer sign (+) Hissing, snoring Exploding, moist Listen to the lungs Alveolar reduction n = 162 89 155 107 34 63 56 56 118 158 136 23 27 23 117 Ratio (%) 54,9 95,7 66,0 21,0 38,9 34,6 34,6 72,8 97,5 84,0 14,2 16,7 14,2 72,2 79 48,8 82 50,6 The results in Table 3.5 show that up to 97.5% of patients have tachypnea and 95.7% of patients have respiratory muscle spasms These are the most common physical symptoms The next is hypertension (84.0%), fast accounted for 72.8%, barrel-shaped signs accounted for 54.9% The percentage of patients who heard lung with wheezing or snoring accounted for the highest rate (72.2%), followed by alveolar murmur reduction (50.6%) and moist, explosive rashes (48.8%) The percentage of patients with spontaneous neck veins was naturally similar, responses to neck veins (+) and hepatomegaly were similar (38.9%; 34.6%) 3.1.2 Subclinical characteristics 3.1.2.1 ECG results Table 3.10 ECG results ECG manifestations Results n=162 Ratio (%) Right atrial thickening 23 14,2 Right ventricular thickening 36 22,2 Right atrial thickening + right ventricular thickening 11 6,8 Left atrial thickening 21 13,0 Left ventricular thickening 16 9.9 10 Arrhythmia Atrial systolic 1,2 Ventricular ectopic 1,9 Supraventricular tachycardia 1,9 Atrial fibrillation 11 6,8 86 53,1 Right bundle branch block 49 30,2 Left bundle branch block 1,9 Ischemic heart disease Conductive disorders Block A-V level I The proportion of patients with right atrial thickness is 14.2% and right ventricular thickness is 22,2%; left atrial thickness on the electrocardiogram is 13% and left ventricular thickening accounts for 9.9%; Atrial fibrillation accounts for 6.8%; Ischemic heart disease accounted for 53.1%; right bundle branch block is 30.2% and left bundle branch block is 1.9% 3.1.2.2 Echocardiography results Table 3.11 Results of some echocardiography indicators Echocardiography index n=162 Ratio (%) ± SD Right ventricular diameter (mm) Dd (mm) EF (%) Increase No increase Increase No Increase Decrease ( 50% of coronary arteries is most common in LAD II (16.1%), followed by LAD I (14.8%), followed by RCA II, LCX II with 7.1% % and RCA I, LCX I together accounted for 5.4% No coronary artery stenosis was found in LM, LCX III and RCA III The degree of stenosis ≥ 70% of coronary artery is most common in RCA II (17.9%), followed by LAD II, RCA I together accounting for 12.5% and LAD I (10.7%) The lowest rate is LM (1.8%) Table 3.30 Relationship between damaged coronary artery location and stage of disease Location of coronary artery lesions LM Stage II n=31 Ratio (%) 3,2 Stage of disease (n = 56) Stage III n=16 Ratio (%) 0 n=9 RCA 11 35,5 43,8 LAD 13 41,9 31,3 LCX 19,4 25 The results of Table 3.30 show that the number of patients with coronary artery stenosis stage II is 31/56 patients (55.4%), phase III is 16/56 patients (28.6%) and stage IV 9/56 patients (16.1%) Stage II of the disease, lesions of LAD arm were the most common (41.9%), followed by RCA arm (35.5%), at least LM arm (3.2%) In Stage III, RCA lesions were the most common (43.8%), followed by LAD (31.3%), LCX had the lowest rate (25%), no patients had lesions at LM Stage IV is the most vulnerable in LAD (44.5%), 14 followed by RCA (33.3%) Stage III and Stage IV no patients had lesions in the LM arm Table 3.31 Relationship between damaged coronary artery location and disease subgroup Location of coronary artery lesions n % n LM RCA LAD LCX 0 0 0 0 17 23 11 A Disease subtypes (n = 56) B C Tỷ lệ n Tỷ lệ (%) (%) 42,9 57,1 12 36,4 51,5 15 36,6 56,1 50,0 40,9 The results of Table 3.31 show that no patients with coronary artery stenosis in group A Group B and group C have coronary stenosis in the branches Group D does not have coronary artery stenosis in the LM arm And group B had the highest proportion of coronary artery stenosis at branch sites, followed by group C, at least in group D Table 3.34 Relationship between artery branch location and lesion and lung X-ray image X-ray image n = 56 Emphysema Bronchial wall Location of coronary artery lesions LM RCA LAD LCX n Ratio n Ratio n Ratio n Ratio (%) (%) (%) (%) 1,8 17 30,4 20 35,7 10,7 1,8 17 30,4 20 35,7 10,7 15 thickening Dirty lung image Redistribution of blood vessels Tear-dropped heart shape Cardiac / thoracic index> 50% 1 1,8 1,8 14 14 25 25 16 16 28,6 28,6 6 10,7 10,7 0 5,4 10,7 0 1,8 10,7 10,7 7,2 The results of Table 3.34 show that, among the lesions on the X-ray image, patients with LAD had the highest incidence, followed by RCA and LM with the lowest incidence Table 3.35 Relationship between damaged coronary branch position and right ventricular diameter, Dd, EF on ultrasound Echocardiography index n = 56 Right ventricul ar diameter (mm) Dd (mm) LM Location of coronary artery lesions RCA LAD LCX n Ratio (%) n Ratio (%) n Ratio (%) n Ratio (%) Increase 25 44,6 10 17,9 12,5 23 41,1 No increase 31 55,4 44 78,6 32 57,1 12,5 Increase 16,1 18 32,1 7,2 16,1 16 EF(%) No increase 46 82,1 21 37,5 32 57,1 41 73,2 Decrease ( 30 - 40 mmHg) Medium (> 40 - 70 mmHg) Location of coronary artery lesions RCA LAD LCX n Tỷ lệ (%) n Tỷ lệ (%) 0 n Tỷ lệ (%) 0 Tỷ lệ (%) 0 3,6 7,2 0 10,7 11 19,6 1,8 17 Significant (> 70 mmHg) The mean of pulmonary pressure (mmHg) ( SD) 0 35,8±13,0 0 36,1±14,0 0 34,9±12,1 0 37,7±18,6 ± The results in Table 3.36 show that there is no coronary injury in patients without pulmonary hypertension Mild and moderate pulmonary hypertension, most common lesions were LAD arm (7.2% and 19.6%), followed by RCA arm (3.6% and 10.7%) LCX branching is common in patients with the highest average systolic pulmonary artery pressure (37.7 ± 18.6 mmHg), RCA lesions are common in patients with systolic pulmonary artery pressure with the mean of 36.1 ± 14.0 Chapter DISCUSSION 4.1 Clinical and subclinical characteristics of research subjects 4.1.1 Clinical characteristics Physical symptoms: our research results (Table 3.5) show common symptoms: barrel-shaped chest (54.9%); spasms of the respiratory tract (95.7%); snoring, snarling (72.2%) As commented by many other authors such as Nguyen Chinh Dien, Nguyen Thi Kim Oanh, the lips and head of the limb had 107/162 patients (66.0%), this is a common symptom during exacerbation due to patients with impairment Respiratory Breathing rate> 20 breaths / minute accounted for the majority of 158/162 patients (97.5%) as commented by Nguyen Thi Kim Oanh 92/100 patients (92%) 18 Increasing blood pressure we met 136/162 patients (84%), higher than the general prevalence rate in the Vietnamese population because the study subjects were chronic obstructive pulmonary disease, the majority of smokers - risk factors for cardiovascular disease and common age ≥ 60 years - is the age with a higher incidence of hypertension 4.1.2 Subclinical characteristics Right atrial thickening, right ventricle thickening, right atrial thickening + right ventricle has 75/162 patients (accounting for 46.3%) Our results are consistent with Nguyen Thi Thuy Nga (35.8%) and Stolz D 76/167 patients (45.5%) and lower than the research results of the authors Nguyen Chinh Dien 72 / 102 patients (accounting for 70.6%) It can be explained that the authors did not study in patients with arrhythmia, valvular heart disease, cardiomyopathy, associated myocardial ischemia The arrhythm we encountered in 19/162 patients accounted for 11,7%, including ventricular tachycardia in 3/162 patients (1.9%), atrial fibrillation in 11/162 patients (6.8%) According to Shih HT and CS when investigating mobile cardiac arrhythmias in patients with chronic obstructive pulmonary disease, 69% of supraventricular arrhythmias: 83% of ventricular ectopic ventricle, 22% of ventricular tachycardia Ischemia is often associated with chronic obstructive pulmonary disease because it usually occurs in smokers In our study, 86/162 patients (53.1%) This result is higher than the research of Nguyen Thi Kim Oanh with this rate is 12% Mapel D.W compared with COPD group had 33.6% cases of ischemic heart disease higher than group without COPD (27.1%) 4.1.3 The incidence of cardiovascular disease in patients with chronic obstructive pulmonary disease 19 Our study in Table 3.15 found that, among cardiovascular diseases, hypertension accounted for the highest proportion (84%), followed by ischemic heart disease (57.4%), arrhythmia heart rate accounts for 45.1%, heart failure accounts for 50.6% The rate of hypertension in our study is higher than that of the author Nguyen Thi Kim Oanh with 37/100 patients (37%) because at present, the condition of atherosclerosis, overweight is a common and increasing cause increase The rate of our arrhythmia is lower with the review of author Nguyen Thi Kim Oanh with 76/100 patients (76%) This is because we did not choose patients with chronic obstructive pulmonary disease with tachycardia sinus Because patients may be hospitalized with fever, shortness of breath and patients treated with salbutamol increase the heart rate but this tachycardia is not due to cardiovascular disease Our research is higher than that of Nguyen Thi Kim Oanh (12%) because of ischemic heart disease, which is common in patients with chronic obstructive pulmonary disease, a consequence of coronary artery disease Again, due to atherosclerosis, chronic hypoxia in severe patients, the heart failure rate in our study was 50.6%, similar to that of authors Ngo Quy Chau and Nguyen Chinh Dien (40 , 1%) because of the same cardiovascular disease study in patients with chronic obstructive pulmonary disease but higher than the research result of Nguyen Thi Kim Oanh (22%) because He studies the authors were not chronic obstructive pulmonary disease Right and total heart failure are an indispensable consequence of chronic obstructive pulmonary disease and are common in the advanced and very severe stages of the disease 4.2 Results of computerized tomography of multiple arteries in patients with chronic obstructive pulmonary disease 4.2.1 Characteristics of patient distribution according to the number of coronary artery lesions 20 Our research results show that (chart 3.3) only 1.8% of patients have normal coronary arteries The majority of patients had narrow coronary artery stenosis (51.8%) The percentage of patients with stenosis of the coronary artery is 28.6% and all stenosis accounts for 17.9% This comment is not the same as Pham Viet Ha's comment when studying coronary artery lesions in patients with diabetes: the majority of patients have 2-branched lesions, of which 2-arm injuries account for 32.3% (21 / 65), 3-branched lesions accounted for 21.5% (14/65) This is understandable because the characteristics of coronary lesions in diabetes are widespread, mixed lesions (including soft atherosclerosis, mixed atherosclerotic, calcified atheroma) 4.2.2 Characteristics of patient distribution according to location of coronary artery lesion In our study, the proportion of patients with chronic obstructive pulmonary disease was surveyed for CT scan with general coronary artery stenosis accounted for 60.7% LAD branches are the most common, accounting for 35.7%, followed by RCA (30.4%) The proportion of patients with LCX stenosis is 10.7% Only 1.8% of patients have LM (chart 3.4) This result is consistent with Vu Kim Chi in the study of CT scan values 64 sequences assessing coronary lesions: the most common is LAD 102/121 (84.2%), followed by RCA 57 / 121 (47.1%), LCX 55/121 (45.4%) and LM accounted for the lowest rate of 10/121 (8.2%) However, the higher incidence of branches compared to us may be due to the smaller number of patients in our study (56 patients versus 121 patients) 4.2.3 The degree of stenosis of the coronary arteries on multidisciplinary computed tomography Our research results in Table 3.27 show: 21 * Left common coronary trunk (LM): In our study, the general stenosis at different levels on CT 384 sequence was 8/56 patients (14.3%), in which there was narrow case on 70% of vascular diameter, accounting for ,8% Pham Viet Ha's study of diabetic patients showed that the prevalence of LM was 30.8%, of which 4.6% was narrow> 50% and 3.1% was narrow> 70% Perhaps the difference between our study and Pham Viet Ha may be due to the smaller number of our patients and the study of coronary artery damage on two different subjects: chronic obstructive pulmonary disease and diabetes mellitus * Main branches of coronary artery: In our study, the narrowest rate was 50%, the most narrow in LAD II (16.1%) and LAD I (14.8%), then RCA II, LCX II accounted for 7.1% and RCA I, LCX I all accounted for 5.4% The vulnerability characteristics in our study are generally consistent with the conclusions of Vu Kim Chi's study (2013) with the narrowness of 50%, the most narrow rate is LAD II (55.3%), LAD I (50.4%), RCA II (31.4%), LCX II (30.5%) and Pham Viet Ha with the highest narrow ratio were LAD I (18.5%) and then RCA II ( 10.8%), LCX II (10.8%) In our study, the narrowest rate was 70%, the most narrow in RCA II (17.9%), followed by LAD II and RCA I, both were 12.5%, followed by LAD I and RCA III are all 10.7% The lowest rates are LM and LCX III (1.8%) This result is different from that of Pham Viet Ha which was the most narrow LAD II (47.7%) and RCA I (30.8%) then LAD I (26.2%), LCX II (15.4) Author Vu Kim Chi also met the most in LAD II (55.3%), LDA I (50.4%), followed by RCA II (31.4%), LCX II (30.5) Thus, the severe stenosis requiring 22 intervention occurs mainly in the large branches of the coronary artery system, in order from the anterior ventricular artery and then the right coronary artery and the artery Research on coronary stenosis in the stages of chronic obstructive pulmonary disease (Table 3.30) shows that: phase II met the highest rate of coronary artery stenosis (55.4%) followed by stage III ( 28.6%) and Stage IV has the lowest rate (16.1%) In stage II of the disease, LAD branch lesions were the most common (41.9%), followed by RCA (35.5%), at least LM (3.2%) Stage III, the most common RCA lesion (43.8%), followed by the LAD arm (31.3%), the LCX arm accounted for the lowest rate (25%), no patients had lesions at LM Stage IV often had lesions in LAD (44.5%), followed by RCA (33.3%), LCX lesions 22.2% and no patients had lesions in LM arm Thus, coronary artery damage in the stages of chronic obstructive pulmonary disease is also the most significant LAD branch lesion, followed by RCA and LCX damage accounted for the lowest rate The study of the location of coronary artery lesion with subtypes of chronic obstructive pulmonary disease (table 3.31) showed that: group A had no patients with coronary artery lesions Group B and group C both have coronary artery lesions and account for similar proportions between branches Group D has no LM arm injury, and the percentage of lesions in the remaining branches is lower than in group B and group C This is understandable because there have been studies of associations between chronic obstructive pulmonary disease and coronary artery disease the more severe the chronic obstructive pulmonary the more calcification and the worse coronary artery damage Particularly in group D, the rate of coronary artery lesions is low because this group is high-risk, symptomatic, exacerbated in 12 months and often hospitalized for intensive care, so 23 patients in this group are few, has not yet accurately reflected the rate of coronary artery damage Similar to blood biochemical results and respiratory function measurements, the results in Table 3.34 show that, among the lesions on X-ray images, patients with LAD had the highest incidence, followed by RCA and branches LM had the lowest incidence: emphysema and bronchial wall thickening with coronary artery stenosis, the highest rate was found in LAD arm (37.5%), followed by RCA (30.4%) and lowest when there is damage in the cleavage (1.8%); Dirty pulmonary images and redistribution of blood vessels had the highest rate of coronary artery lesions, with LAD at 28.6%, followed by RCA at 25% and LCX at the same time have a rate of 10.7% The lowest is branch LM (1.8%); The teardrop-shaped heart usually had the highest rate was the LAD arm (10.7%), followed by the RCA arm (5.4%), no patients with LM and LCX stenosis and cardiac / thoracic index> 50% of the highest proportion was narrow branches RCA and LAD (10.7%), followed by the narrow branches of LCX (7.2%), the lowest proportion of branches LM (1.8%) In summary, our study has identified the relationship between blood biochemistry, blood gases, pulmonary ventilation and pulmonary Xq The highest proportion of coronary artery stenosis and lesions is still LAD and RCA Particularly, the relationship between the echocardiography results in coronary artery stenosis in Table 3.35 shows that most of the measurements on echocardiogram are not the same as the results of coronary artery stenosis in blood biochemistry, blood gas and Lung X-ray: right ventricular diameter increased most in the LM segment (44.6%), followed by the LCX arm (41.1%) and the least LAD arm (12.5% 0.Dd was most increased in the segment) the segment of RCA (32.1%), followed by the branch LM and LCX (16.1%) and at least the branch LAD (7.2%) and EF dropped the 24 most in the segment LM and LCX (17.9%) ), followed by RCA (14.3%), the lowest was LAD (10.7%) The results in table 3.36 showed that there was no coronary injury in patients without increased dynamic pressure Pulmonary hypertension Moderate and moderate increase in pulmonary artery pressure, most common is LAD (7 , 2% and 19.6%), followed by RCA (3.6% and 10.7%) LCX episodes were most common in patients with the highest average SBP pressure (37 , ± 18.6 mmHg), RCA lesions were observed in patients with mean pulmonary artery pressure index 36.1 ± 14.0 CONCLUSION Clinical characteristics, ECG, echocardiography and some cardiovascular diseases in patients with chronic obstructive pulmonary disease - The prevalence of chronic cardiovascular disease in chronic obstructive pulmonary disease: hypertension (84%), arrhythmia (45.1%), ischemic heart disease (57.4%), Chronic heart defects (46.3%), heart failure (50.6%) - ECG: Atrial fibrillation 6.8%, ischemic heart disease 53.1%, ischemic heart disease accounts for 53.1%, right bundle branch block is 30.2% and left bundle branch block is 1.9% - Echocardiography: Echocardiography has more diagnostic value of right ventricular hypertrophy on the ECG: right ventricular diameter increases on echocardiography 35.8% and right ventricular thickening on ECG only 19.8% Computerized tomography of coronary arteries in patients with chronic obstructive pulmonary disease 2.1 Coronary lesions in patients with chronic obstructive pulmonary disease 25 - 51.8% of patients had one coronary stenosis, 28.6% had coronary stenosis and all branches were 17.9% - Stenosis of the common coronary artery 60.7%, LAD branch 35.7%; RCA30.4%; LCX 10.7% and 1.8% have LM - Severe coronary artery injury and degree of calcification both had the most significant ventricular artery bypass (LAD) damage, followed by the right coronary artery (RCA) and exponential artery damage (LCX) account for a lower percentage The lowest is the left common coronary trunk (LM) 2.2 Relationship between coronary artery lesions on polyclinism and clinical, subclinical in patients with chronic obstructive pulmonary disease Determining the correlation between clinical and subclinical coronary lesions in patients with chronic obstructive pulmonary disease, the highest incidence is still LAD and RCA Particularly for measurements on echocardiography (right ventricular diameter, Dd, EF, systolic pulmonary pressure) not give the above results The determination of coronary artery stenosis that greatly affects the severity and severity of chronic obstructive pulmonary disease and the more severe the chronic obstructive pulmonary disease, the greater the risk of coronary artery stenosis RECOMMENDATION Chronic obstructive pulmonary disease and cardiovascular disease often work together and increase the severity of both Therefore, comprehensive examination and testing to screen and detect early cardiovascular manifestations in patients with chronic obstructive pulmonary disease is necessary to contribute to diagnosis, 26 follow-up, treatment and treatment disease quality, improve the quality of life in patients with chronic obstructive pulmonary disease The more severe the chronic obstructive pulmonary disease, the more coronary artery calcification and the greater the damage to coronary artery branches and coronary artery disease, the greater the severity of chronic obstructive pulmonary disease going into the analysis of clinical and subclinical symptoms, especially the early detection and details of coronary lesions on multidisciplinary CT scans to contribute to timely diagnosis and treatment of dynamic diseases coronary artery disease in patients with chronic obstructive pulmonary disease, improving the quality of life for patients with chronic obstructive pulmonary disease However, the number of patients studied is small, so it does not accurately reflect the incidence of artery stenosis may be seen in patients with chronic obstructive pulmonary disease, so it is necessary to conduct research with a larger number of patients 27 ... tables, 15 pictures, 05 charts, 05 graphs, 03 diagrams, 131 references: 51 Vietnamese, French and 79 English 3 Chapter OVERVIEW 1.1 CHRONIC OBSTRUCTIVE PULMONARY DISEASE According to BOLD (The Burden... coronary image, a collimated probe and a thinner slice thickness increase the shutter speed thus reducing shooting time in a meaningful way It is hoped that in the future, coronary angiography may... Natural floating neck veins Hepatomegaly Hepatic venous feedback (+) Fast pulse (> 90times / minute) Breathing> 20 times / minute Increase of blood pressure Systolic blowing 3-valve valve T2 strong,