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MINISTRY OF HEALTH OF THE REPUBLIC OF KAZAKHSTAN KARAGANDA

STATE MEDICAL UNIVERSITY

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19 2014

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19 2014

THE WORLD OF SCIENCE AND YOUTH:

TRADITION AND INNOVATION

Materials of international conference of young scientist 19 of February 2014 year

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. The world of science and youth: tradition and innovation Materials of international conference of young scientist : - , 2014. 208.

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The actual problems of modern medicine considered in the compilation, such as such as ecology and human health, problems of clinical medicine and laboratory diagnostics.

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ISBN ,

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UDC 616.831-005.1/.379-008.64- I.A. Kadyrova

APPLICATION OF PROGNOSTIC MODEL FOR DETERMINING THE PROBABILITY OF

STROKE IN PATIENTS WITH TYPE 2 DIABETES

Karaganda State Medical University, Karaganda Research supervisor F.A.Mindubaeva Introduction. Acute ischemic stroke is not only medical but also a social problem. High percentage of mortality and disability in cerebrovascular diseases has led to understanding that a stroke, as well as chronic cerebral ischemia is easier to prevent than to treat, so now a lot of attention is paid to prevention. Type 2 diabetes mellitus (the DM) significantly increases the risk of stroke [16].

Currently there is a rapid increase in the incidence of diabetes mellitus now, dominant share of which is type 2 diabetes. Type 2 diabetes is up to 95% of all cases of diabetes [1]. The significance of this trend is dramatically, not only within manifestation of disease by itself, but also the close pathogenetic association with the development of micro-and macrovascular complications.

Diabetic macroangiopathy is a frequent complication of diabetes with a primary lesion of the coronary, cerebral and peripheral blood vessels. One of the significant pathology that develops on the background of macroangiopathy - an acute cerebrovascular accident (stroke), and encephalopathy as its predecessor. Stroke is one of leading causes of death in the world and is the major reason of permanent disability. [15] According to WHO, more than 30 million cases of stroke registered annually [7]. Disability as a result of a stroke varies from 40 to 80% [13].

According to the MRFIT research the risk of stroke among patients with diabetes was 2.8 times higher than in patients without diabetes. Stroke occurs in 2.08 times more frequently in patients with diabetes according to our study [4].

The main theories to explain the development of macroangiopathy in type 2 diabetes include hyperglycemia, dislipidemia, oxidative stress, insulin resistance, hyperinsulinemia, endothelial dysfunction. Difficult to say which mechanism is primary, but it is absolutely clear that they are part of each other and aggravate the disease, accelerating the formation of macrovascular complications [3,6].

Due to the high risk of stroke in patients with type 2 diabetes it is necessary to carry out preventive measures. It is necessary to develop a method that forecasts the risk of stroke, taking into account possible risk factors to implement an effective prevention of stroke in patients with diabetes.

On the base of Centre of primary health care in Karaganda standard laboratory and hardware methods of investigation were performed. This methods are conducted regularly in patients with type 2 diabetes. A mathematical model predicting the likelihood of stroke in patients with type 2 diabetes was developed according to this data.

The purpose of the study was to develop a mathematical model of "stroke-risk factors" to determine the likelihood of stroke in patients with type 2 diabetes.

Materials and methods.In the laboratory study included 94 participants aged 40 to 83 years, with an equal inclusion of women and men of different national and ethnic origin. There were patients with diabetes mellitus in the compensatory stage with cerebral disorders in the group, 9 of them had a stroke for the current year. The group of comparison consisted of 34 participants with diabetes without stroke matched for age and sex. The criteria for inclusion in the control group were age 40-80 years, normal blood pressure, BMI within 18,5-25,0.

Surveys conducted with all of the participants in the study. The questionnaire presented questions to identify risk factors (gender, age, height, weight, family history of diabetes and stroke, the presence of hypertension and its duration, the presence of diabetes and its duration, smoking, alcohol abuse, lack of exercise, diabetes, unbalanced diet, obesity, emotional stress, use of oral contraceptives), as well as questions that reveal the presence of symptoms of ischemic attacks (sudden headache, nausea, ringing in the ears, dizziness, weakness, loss of consciousness, motor and speech impairment).

After conducting the survey, all participants underwent the following survey methods.

Measurement of BMI. Body mass index was calculated by Adolph Quetelet formula:

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Measurement of systolic and diastolic blood pressure. The patient was asked to relax and calm down for 15 minutes before measurement. SBP and DBP were measured by the method of Korotkov with mechanical tonometer.

Measurement of respiratory rate. Respiratory rate was measured by the auscultatory at rest.

Measurement of heart rate. Heart rate was measured by tactile method for a minute at rest.

Testing blood glucose blood sampling was performed in the morning on an empty stomach in the standard terms. For blood collection were used tubes Vacutainer, the level of glucose in the blood was determined by the method of Somogyi-Nelson.

Determination of glycated hemoglobin. Blood sampling was performed in the morning on an empty stomach in the standard terms. For blood collection were used tubes Vacutainer. Determination of glycated hemoglobin produced by using immunological reagents Vital and DR spectrophotometer with a wavelength 443 nm.

Studies of blood coagulation (PTI, amount of fibrinogen, platelet aggregation, APTT). Blood sampling was performed in the morning fasting in the standard terms. For blood collections were used tubes Vacutainer. The analysis was performed on the single-channel analyzer parameters of hemostasis Clot-1.

Determination of blood biochemical parameters (cholesterol, triglycerides, ALT, AST, total bilirubin, direct bilirubin, urea, creatinine, total protein). Blood sampling was performed in the morning fasting in the standard terms. For blood collections were used tubes Vacutainer. For analysis reagents used with the company Vital biochemical analyzer BioSystemA-15.

Electrocardiogram. ECG study was conducted in 12-lead electrocardiograph for BTL-088D, United Kingdom, 2011.

CDSM of brachiocephalic trunk. CDSM of b / c the barrel held scanner MEDISON SONOACE X8, 5-12 MHz linear probe.

According to the questionnaires and surveys conducted by expert assessments by specialists (neurologist) was diagnosed with the presence of cerebrovascular accidents.

Statistical processing of the measurement was carried out according to conventional methods in the program Statistica. Square correlation matrix was set to determine the correlation coefficient. The distributions of the parameters subordinated to the normal distribution law [8].

The results of the study. There is a significant correlation between the event "stroke" and SBP, duration of hypertension, the percentage of stenosis of the carotid artery in the group of patients with diabetes and cerebrovascular disorders. It is interesting to note that there is a significant correlation coefficient between diabetes disease duration and duration of hypertension. Also, there is a significant correlation coefficient between glycosylated hemoglobin and duration of hypertension.

The correlation coefficients are given in the table.

Table of summarized data.

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There was a necessity to create a matrix with coded values to develop mathematical model, because these studies included both qualitative and quantitative characteristics in different units of measurement.

The next step was to determine the regression coefficients by method of logistic regression.

These factors were the basis for the development of a mathematical model to predict the risk of stroke [9]. The mathematical model allows: to determine the risk of stroke in a patient or a tendency of stroke rise in social groups, to explore the character of change in the probability of occurrence of stroke

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according to operating factors, to assess the degree of influence of the studied factors on the probability, to predict the occurrence of stroke for given levels of the factors, to determine the optimal levels of factors to indicate required values of parameters [8].





y-its occurrence;

b1.... bi-regression coefficients of factors x1... xi x1... xi-studied factors The processing of the regression coefficients were tabulated.

The following is a regression equation that indicates the likelihood of stroke in patients with type 2 diabetes.

Where A=(8.155-0.240133-1.93289-4.16929+2-1.24113+3.9+5.31-3.24604-4.43646+7It is noteworthy that tests of significance were p = 0.02038, with hi2 = 54.174 for the second group (patients with diabetes), and for the first group of p = 0.03683, with hi2 = 51.352. These significance tests confirm performance of the model.

Regression equation is close to functional. The derivative of the regression equation allows to determine the development trend of the probability of stroke:

Where: a= b0+b1++bi- z= exp b0+b1+bi *x Function of the probability of each risk factor is hyperbole, asymptotically approaching 1, and the function of the probability of change of speed - hyperbole that tends to 0.

The resulting dependence of the rate of increase of stroke can be used to determine the terms of hospitalization of the patient.

Discussion. There are significant correlation coefficients between the event "stroke" and elevated SBP, duration of hypertension and a high percentage of carotid stenosis, ie the presence of these factors already predetermines the development of cerebrovascular accidents. It takes such a low number of parameters in patients with diabetes for the development of stroke, due to pathologically altered state of the vascular wall, their changed architectonic and endothelial dysfunction.

The glycation end products (GEP) formed during the diabetes disesase. GEP circulating in the bloodstream bind the proteins of the extracellular matrix of blood vessels. In addition, GEP have the following effects: increase permeability between endothelial cells, violate the bioavailability of NO to the smooth muscle cells of arterioles and initiate the secretion of cytokines by macrophages -primary mediators of inflammation [14]. These processes lead to endothelial dysfunction, thickening of the basement membrane, decreased elasticity, increased vascular tone, the violation of their architectonic.

According to McDermott, glycosylation end products independently contribute to the development and maintenance of high blood pressure in patients with diabetes mellitus, disrupting normal sensitivity to the action of the vessel walls of vasodilator substances. The irreversibility of the molecules glycosylation end products explains the continued progression of micro-and macrovascular complications even with very good compensation of diabetes [5].

Violation of NO-producing endothelial function is primarily due to the development of angiopathy and atherogenesis. Inadequate NO production not only leads to reduced vascular relaxation and spasm, but also to an increased vascular permeability of proteins and lipoproteins, to the rapid

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proliferation of smooth muscle cells to unhindered expression of adhesion molecules on endothelial cells to increased thrombosis. All of these processes lead to an imbalance between vasodilator and vasoconstrictor, prothrombotic and anti-thrombotic, anti-inflammatory and pro-inflammatory, antisclerotic, proliferative factors in side of prevalence the latter [6].

As pointed Mkrtumian [6]et al in their work altered endothelium expresses adhesion molecules, including ICAM-1, to facilitate the penetration of monocytes crowded lipids in the subendothelium.

These abnormalities are probably promote lipid accumulation in the vascular wall, proliferation and migration into the intima of smooth muscle cells of arteries and increase their production of collagen and elastin, developing platelet microaggregates. Recent shape the microembolisms vasa-vasorum large arterial vessels with local changes of the vascular wall, which ultimately leads to the development of atherosclerosis and thrombosis.

There are three components of the underlying etiology and pathogenesis of stroke: an inadequate cardiovascular activity, altered state of brain vessels and disturbances in coagulation [11,12]. The above pathological processes lead to abnormalities in both the cardiovascular system and the inadequacy of blood supply of the brain, atherosclerotic vascular changes and activation of coagulation processes [10,17,18].

As a result, the long duration of hypertension, high SBP and the high percentage of carotid stenosis in patients with type 2 diabetes are sufficient risk factors for the appearance of stroke.

Conclusions. The research led to the following conclusions about sufficient quantity of three risk factors (elevated SBP, prolonged hypertension, and a high percentage of stenosis of the carotid artery) for the occurrence of acute ischemic attack in patients with type 2 diabetes, due to a significant correlation coefficient between the event "stroke" and examined factors. A methodology was developed to predict the occurrence of stroke in patients with type 2 diabetes. It was based on standard methods regularly conducted in hospitals. The analysis of the mathematical model allowed us to establish the rate of increase of stroke in order to monitor its trend and provide timely hospitalization to the patient.

List of references

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5. .. // / 2- . .: , 2001. . 6. , ., .., .. .

7. : : // http://www.who.int/mediacentre/factsheets/fs312/ru/index.html 8. .. .- ., -. - 2006. 9. , . ., . ., ..

10. .., .. // , 2004, 1, . 62-67.

11. .., .. : . 2- , . .: , 2001. 240 .] 12. .., .. . : " ", 2008. 224 .

13. .., .., .. : , , //. .: .- .- 2005.- . 143-151.

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14. .., . . , . , . // .-2011.- 11.-. 3- 15. .. // . - 2005. - . XXXVII, .

1-2. - .93-104.

16. .., .., .. , 2 // .-2012.-3. URL:http://www.ngmu.ru/cozo/mos/article/text_full.php?id= 17. Gosk-Bierska I., Adamiec R., Alexewicz P., Wysokinski W.// IntAngiol,2002, 2,P. 128-133.

18. Vinik A., Erbas., Park ., Nolan R., Pittenger G.// Diabetes Care, 2001, 8,P.1476-1485.

616.235-002-053-07-08-036. L.M. Koishibaeva, 1st year magister 1, P.S. Semenikhina, General Medicine faculty Pediatrics specialty intern

ANALYSIS OF THE ACUTE BRONCHIOLITIS EPIDEMIOLOGY, CLINICAL COURSE,

DIAGNOSTICS AND TREATMENT CHARACTERISTICS OF CHILDREN IN

KARAGANDA REGION

Karaganda State Medical University, Karaganda 1,2.

Scientific supervisors: professor B.T. Tukbekova, associate professor S.T.Kizatova Relevance: Acute bronchiolitis (AB) is a disease mostly affecting children under two years and characterized with the generalized obstruction of the bronchioles and small bronchi. [1] According to the results of the prospective multicentral study of AB etiology on the modern stage conducted in USA in 2007-2010 of all the participants 72% had respiratory syncytial virus (RSV), 26% had human rhinovirus (HRV), while all other viruses and bacteria were each 8% (influenza, parainfluenza, cytomegalovirus, adenovirus, mycoplasma, chlamydia and etc.); also in 30% of cases there were two and more infectious agents. [2] There was an increase in the incidence of AB during the last decades throughout the world.

There is a statistically significant seasonal peak of the morbidity in winter and spring time. The majority of patients with AB were of male gender, premature infants or those with co-existing cardiac or respiratory disease. [3] Nowadays there is no any golden standard of AB diagnostics. According to the American Academy of Pediatrics and its 2006 clinical practice guideline the AB diagnosis can be used when a child has rhinitis, tachypnea, wheezing, cough, crackles, use of accessory muscles, and/or nasal flaring. [3], [4] The evidence based medicine recommendations on the AB treatment include only supporting oxygen therapy (when having hypoxemia) and attention to fluid and nutritional status. The benefit of using of the adrenomimetics stays unclear since according to many RCTs data only 1 of 4 children have positive effect while using salbutamol. More notable effect is observed when using nebulized epinephrine with additional systemic dexamethasone depending on the severity of childs condition.

The use of antibiotics is recommended only for children with high body temperature or other symptoms of bacterial infection (leukocytosis, increasing of ESR) or after the bacteriological test. But according to the Integrated Management of Childhood Illness (IMCI) program employed in Kazakhstan the AB treatment consists of antibiotics, oxygen therapy and antipyretic drugs plus fluid intake control. [1], [4], [5], [6] Objectives: To analyze the AB morbidity on the base of 6th somatic department of Regional Children Clinical Hospital (RCCH) of Karaganda in 2011-2013 years.

Materials and Methods: The material of this study were children under one year with AB who were treated in RCCH of Karaganda in 6th somatic department since 2011 till 2013. We analyzed case histories of children with AB (there were 226 boys (58.7%) and 159 girls (41.3%)), including (5.5%) children treated in the Department of Anesthesiology, Reanimation and Intensive Care (DARIC): 12 girls (57%) and 9 boys (43%). There were 270 (70%) children under 3 month, (21.3%) children from 3 to 6 month and 33(8.7%) children older than 6 month; in DARIC there were 17 (81%) children under 3 month and 4 (19%) children from 3 to 6 month. The complex survey of sick

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children included anamnesis gathering, objective inspection, laboratory tests - complete blood count, acid-base status analysis with O2 saturation, instrumental tests chest X-ray and bacteriological examination of sputum.

Results and discussion: The conducted analysis shows that since 2011 till 2013 385 children were treated with the AB diagnosis, including 40 (11%) children in 2011, 72(19%) children in and 273(70%) children in 2013. Also AB holds the first place in the morbidity structure in these years.

While studying the anamnesis data we detected that before visiting emergency room During these days this time 87.5% of children received medical attention at home: 58.7% received mucolytics, 25% received antibiotics, 13.8% got antipyretic therapy and 10% received salbutamol, but in 91% of cases the treatment was ineffective and in 9% of cases there was only transitional and mild effect.

Considering the mentioned risk factors only 10% of children had contact with infected person and 10% more linked the beginning of the illness with the undercooling. 20% of children had diathesis during their life and 6.25% had family history of bronchial asthma.

Based on the American Academy of Pediatrics criteria of AB 82.5% of children had rhinitis;

98.8% of children had tachypnea (75% had respiration rate (RR) 50-65 per minute, 20% had RR 66- per minute and 3.8% - above 86 per minute); 100% of children had use of accessory muscles, and/or nasal flaring; auscultative picture included diminished breath sounds with wheezing, crepitation and crackles in 58.8% of cases and coarse breath sounds with wheezing, crepitation and crackles in 41.2% of cases.

Based on the WHO criteria of the IMCI program 10% of children were classified as having pneumonia and remaining 90% of children had severe pneumonia. This classification considered RR, use of accessory muscles and general danger signs: 11.3% of children werent able to drink or breastfeed, 30% of children were restless and irritable, 5% moved only when stimulated. Note that children having general danger signs usually were hospitalized or subsequently transferred to DARIC.

Treatment of the children with AB was conducted according to the recommendations of the WHO pocket book of hospital care for children. Thus in general 76.3% of children received antibacterial therapy, while in DARIC 92% of children received antibiotics; 60% received corticosteroids, while in DARIC 81% received them; 52.2% received salbutamol, and oxygen therapy was needed in 31.3% of cases.

Most part of children stayed at hospital from 5 to 11 days (74.6%), while children who were in DARIC in 86% of cases needed to stay more than 11 days.

Conclusions: 1. Analysis of data for 3 years shows that AB morbidity picture in Karaganda region corresponds with the previously determined tendencies like prevailing of male gender, AB manifestation age is likely to be under 6 month, and also there is a seasonal peak of the morbidity in winter and spring time.

2. More severe course of the disease with subsequent hospitalization to DARIC usually is observed in children under 3 month of female gender.

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3. AB morbidity stays high and the tendency for the increase in morbidity can be distinguished in latest years; now AB holds one of the first places in the morbidity structure for children under year.

4. All children hospitalized with the AB diagnosis matched the American Academy of Pediatrics criteria, given in their 2006 clinical practice guideline. [4] 5. IMCI diagnostics criteria allowed to classify AB as severe pneumonia that corresponded with the severity of the disease. General danger signs from the IMCI were more often observed among children under 3 month hospitalized or subsequently transferred to DARIC.

6. AB treatment was conducted according to the standard IMCI program recommendations (antibiotics plus oxygen therapy) adding some other clinical guidelines (adrenomimetics and corticosteroids) and it was effective in all cases.

7. The more severe AB progress is associated with longer hospital stay.

1. World Health Organization. Pocket book of hospital care for children. // 2 edition, Geneva, 2013.

study of viral etiology and hospital length of stay in children with severe bronchiolitis. // Arch Pediatr Adolesc Med. 2012; 166(8):700-706.

3. Sakellaropoulou A, Emporiadou M, Aivazis V, et al. Acute bronchiolitis in a paediatric emergency department of Northern Greece. Comparisons between two decades. // Arch Med Sci. 2012; 8(3):509American Academy of Pediatrics. Diagnosis and Management of Bronchiolitis: Clinical Practice Guideline. // Pediatrics. 2006; 118(4):1774- 5. Sumner A, Coyle D, Mitton C, et al. Cost-effectiveness of epinephrine and dexamethasone in children with bronchiolitis. // Pediatrics. 2010; 126(4):623-631.

6. Ferronato E, Gilio AE, Ferraro AA et al. Etiological diagnosis reduces the use of antibiotics in infants with bronchiolitis. // Clinics (Sao Paulo). 2012; 67(9):1001-1006.

: 616. S.I. Omarova, A.R. Ashurmetov, c.m.s., R.I. Ashurmetov

THE PREVENTION OF CARDIOMYO- AND GASTROPATHY

IN HEALTHY PERSON WHO HAS ALCOHOL ADDICT

International Kazakh -Turkish University by named H.A.Yesevi,Turkestan The problems of longevity is actual nowadays. Healthy shape of life wasn`t index of longevity for people of late republics of Union Independent Countries. People continuing eat abundantly, drink alcohol, smoke, using allergic products and clothes. All of this at the end make of different cardioand gastropathies.

The aim of reseaching to learn possibility prevention of cardio- and gastropathy in healthy people who has alcohol addict.

Among many problems which are actual today for our society, the problem of alcoholism is on one of the first places. In last times the problems of infant and young`s alcoholism take up impotant place in the world. The harmful use of alcohol is a leading risk factor for premature death and disability in the world.

According to World Health Organigation, worldwide alcohol causes 1.8 million deaths (3.2% of total) and 58.3 million (4% of total) of Disability-Adjusted Life Years (DALYs). Unintentional injuries alone account for about one third of the 1.8 million deaths, while neuro-psychiatric conditions account for close to 40% of the 58.3 million DALYs.[] Kazakhstan is in the first place by alcohol abuse in Central Asia, Director of Kazakhstan National Center for Healthy Lifestyle Zhamilya Battakova told Tengrinews.kz.

According to the World Health Organization, we are indeed in the first place in Central Asia.

Judging from this years reports, 10-12 liters of pure spirit fall per each citizen in Kazakhstan. In Tajikistan, Turkmenistan, Kyrgyzstan and Uzbekistan this value is 2-3 times lower, Battakova said.

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According to the statistics, Kazakhstan citizens start smoking at the age of 6-7 and try alcohol when they are 10-12. People excessively consuming alcohol are aged from 25 to 40.

As for female alcohol abuse, its rate has reached and equaled to the male alcoholism, according to the expert. This is happening because women are taking too much on their shoulders: work, family, etc. Women are more prone to alcoholism than men. Female alcoholism is progressing much faster. Men prefer going to a bar to get drunk and maybe even pickup a fight. While women are more prone to drinking alone, at home and this is the very reason for solitary drinking, Nuraliyev explained. According to him, 35 percent of all Kazakhstan people who regularly consume alcohol are women.[3] There are more than a few apparent alcohol related deaths and scores of less instantly recognizable alcohol related deaths.

Conceivably the most incontrovertible alcohol related deaths concern the following: untimely deaths from chronic alcoholism, terminal alcohol overdose, alcohol-related traffic deaths, loss of life from severe alcohol withdrawal symptoms, and the lost of life of children due to severe fetal alcohol syndrome and other fatal birth defects.

Let us be clear. Alcohol related deaths are the result of abusive drinking, alcohol abuse, and/or alcoholism, all of which usually take place over a period of several years.

Traffic crashes are the greatest single cause of death for persons aged 6-33. About 45% of these fatalities are in alcohol-related crashes.

In despite of the inhibition of saling alcoholic beverages till 18 age, in shops this rule didn`t respect. Well-known that alcohol first of all influence to cardiovascular and gastrointestinal sistems.

For reseaching were chosen 20 healthy men at the age of 30-55 years. They drunk 500,0 ml of vodka every evening. Before and after using alcohol blood pressure and heart rate were measured.

They complainted for decreasing or absense of appetite, vomiting, diarrhoea, quality of sleeping. Men were divided into two groups, the first group of men didn`t use nothing. The second group used of hypotensive and antacid drugs in a few doses after drinking alcohol.

In period of from 2010 to 2013 years in the Central Town Hospital of Turkestan enlistmented 386 patient with alcohol intoxicating.

Heart rate and blood pressure were increased in all patients after using alcohol. Men complainted for headache, nausea, vomiting and diarrhoea. In control group heart rate increased up to 100 and more, blood pressure for 15-30 mm. In the morning these indexes decreased, but it were higher primary indexes for certain.

They had other complaints:dryness on mouth, nausea, in two patients were vomiting with bile, also the quality of sleeping changed, they often woke up.

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In second group also marked increasing of heart rate, blood pressure, two men before sleeping drunk 1 tablette of hypotensive ana antacid drugs. Heart rate and blood pressure was normal, but three men had a sense of nausea, dryness on mouth. Marked quick and good sleeping.

Conclusion

So, using of hypotensive and antacid drugs after alcohol, decreased subjective complaints and common clinic indexes, that gave us supposition about preventive action of drugs on cardio- and gastropathies among healthy people who has alcohol addict.Considerating results of our reseach, we hope for partnership among cardiologists and gastroenterologists.

1. Akyrek, O., N. Akyrek, T. Sayin, I. Diner, B. Berkalp, G. Akyol, M. Ozenci, D. Oral. 2001.

Association between the severity of heart failure and the susceptibility of myocytes to apoptosis in patients with idiopathic dilated cardiomyopathy. Int. J. Cardiol. 80:2936. doi:10.1016/S0167X CrossRef 2. Ashrafian, H., M.P. Frenneaux. 2007. Metabolic modulation in heart failure: the coming of age.

Cardiovasc. Drugs Ther. 21:57. doi:10.1007/s10557-007-6000-z CrossRef 3. Basso, C., D. Corrado, F.I. Marcus, A. Nava, G. Thiene. 2009. Arrhythmogenic right ventricular cardiomyopathy. Lancet. 373:12891300. doi:10.1016/S0140-6736(09)60256-7 CrossRef 4. Berko, B.A., M. Swift. 1987. X-linked dilated cardiomyopathy. N. Engl. J. Med. 316:11861191.

doi:10.1056/NEJM198705073161904 Medline 5. http://www.worldometers.info/alcohol/ 6. http://en.tengrinews.kz/markets/Kazakhstan-citizens-drink-most-alcohol-in-Central-Asia-14151/ 7. http://www.pdfqueen.com/alcohol-problem-in-kazakhstan 616.1:796.077. Umer Farooq1, K.M. Zhienbaeva1, M.S. Zhalmakhanov1, M.R. Mukushev1, I.A. Barishnikova

IMPORTANCE AND RECOMMENDATIONS OF INTERPRETATION OF THE

ELECTROCARDIOGRAM OF YOUNG ATHLETES

KSMU, Department of pathological physiology1, Karaganda Research director - d.m.s. prof. Zhautikova S.B. Actuality: ECG is the method of finding: rate and rhythm, orientation, hypertrophy, damage, acutely impaired blood flow, and abnormal electric activity in the heart. Sudden cardiac disease in a young athlete is a tragic and high-profile event. Medical associations for sports events informed the sports associations for the inclusion of a 12-lead ECG in screening tests for all athletes [1]. Although many authors have acknowledged the possible benefits of such an approach [2]. Concern has focused in particular on the idea of mandatory testing, cost effectiveness, the availability of practitioners qualified to interpret ECGs [4]. Professional sports organizations endorsing or implementing screening programs for their athletes, and with the many Heart Associations offering a cautious endorsement to the idea of local programs, volunteer-led testing programs across the world have begun to emerge [3].

Thus, although no detailed guidance for the interpretation of the athlete's ECG exists, many physicians will be called on to interpret an athlete's ECG [5]. A principal obstacle to such interpretation is the

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difficulty in distinguishing physiological effects of training from abnormal patterns. Many clinical and ECG findings that may be a cause of concern in the general population are normal for athletes. In addition, the test characteristics of the ECG for different findings vary according to age, sex, ethnicity, sport, and level of training. In particular, different challenges exist for younger athletes because of the evolution of the ECG with age. Although this article focuses on the diagnostic area presented by ECG screening, we have where possible included suggestions for secondary testing strategies.

Objective: To estimate the effectiveness of ECG use during athletic PPEs.

Method and material: According to this report, we analyzed the 100 good trained foreigner athletes of our university, previously presented by some sports associations in their country.

Originally, 20% (n=20) were considered to have findings possibly associated with cardiovascular disease. However, using the new ESC (European Society of Cardiology) recommendations this percentage was lowered to 11%, which implies a meaningful increase in specificity. The age range of these athletes was 17 to 28 years with 10% female, and most participated in state level sports. In our original analysis of 20 athletes, 80% of the boys and 10% of the girls had abnormal ECGs and 10% were considered to have ECG patterns possibly associated with cardiovascular diseases that warranted further testing. When these 10% abnormal ECGs were evaluated using interpretation of the new ESC criteria, 6% were reclassified to the normal range and only 4% remained in the abnormal category. Thus, implied specificity rises to above 95%. These data seem to support that the new criteria improve the specificity of the ECG as part of the preparticipation examination, but this remains to be tested in a prospective study.

Results and their discussion: Changes in ECG which are related to training included increased QRS voltage. The largest proportion of athletes with ECGs classified as abnormal using previous criteria exhibited isolated increases in QRS voltage. Because of this and other evidence that such voltage correlates poorly with left ventricular mass in young athletes, there is widespread acceptance that in the absence of other markers suggesting actual left ventricular hypertrophy (axis changes, changes in repolarization, atrial abnormalities, increased QRS width), high QRS voltage is not a sufficient reason in isolation to refer an athlete for further evaluation. Therefore we do not recommend further evaluation for any degree of QRS voltage as long as it is isolated (i.e., there are no other findings and it is associated with normal axis, acceptable repolarization, and normal atrial activation).

The next main change is early repolarization in athlete. The finding of ST elevation in V36 with an elevated J point and a peaked upright T wave is present in 50% of trained athletes. It is particularly prevalent in boys. Although a normal echocardiogram in this setting (in the absence of other factors) may allow participation, such athletes should be followed up serially. In athletes, although the mechanism is uncertain, early repolarization seems to regress with age and when training declines and often changes or disappears during exercise or with increasing heart rate. It is important to distinguish these findings from the Brugada-like ECG pattern that is recognized in V12. J wave and/or QRS slurring was found more frequently among athletes with cardiac arrest/sudden death than in control athletes. Of additional note is that ST elevation 2 mm seems to be unusual even in athletes. Sinus bradycardia, prolonged PR interval, and Wenckebach phenomenon are common in athletes as a result of the high resting vagal tone, or significantly lower intrinsic heart rates. Similarly, we do not recommend further evaluation for sinus bradycardia as low as 30 bpm (with sinus arrhythmia, some RR intervals could be prolonged to 3 seconds) or isolated early repolarization. A prolonged PR interval up to 300 ms should not prompt further workup, but longer intervals should be resolved with an exercise test (the PR interval should shorten as vagal tone is withdrawn). Next change in screening of athletes is right ventricular hypertrophy. Various voltage criteria have been recommended for right ventricular hypertrophy including R wave 7 mm in V1, R/S ratio 1 in V1, and the sum of R wave in V1 and S wave in V5/610.5 mm. Until careful studies are made of the voltage measurements in the involved leads (R and S waves in V1/V2 and V5/6) of normal and athletes according to age, we do not recommend that traditional voltage criteria violations trigger further evaluations in athletes 25 years of age. We recommend that voltage-only criteria for right ventricular hypertrophy are, in general, not applicable to young athletes and that additional findings such as right atrial abnormalities (RAA), Twave inversion in V2/3, and/or right-axis deviation are necessary to elicit further evaluation before participating in sports. Although none would contest the need for further evaluation in athletes with QRS duration longer than 120 ms. Left bundle branch block appears to be less common and more ominous than right bundle branch block (RBBB) in asymptomatic athletes. Most computer interpretive programs make RBBB the interpretive statement for QRS durations as short as 106 ms if a RBBB

:

pattern is present. All athletes with a QRS duration 120 ms should be referred for further evaluation.

This is one area where digital analysis can outperform standard visual measurement because the first onset and last offset in all of the leads can be considered. When an isolated RBBB pattern is present at 120 ms duration, most would not refer for further evaluation. T-wave inversion (TWI) has similar prevalence among athletes, suggesting that it is not a training-related phenomenon. Notably, there were no significant differences in absolute values of maximal left ventricular wall thickness between athletes with T-wave inversions and those without. Male athletes are also known to exhibit greater degrees of early repolarization, the voltage criterion for LVH and TWI. Detailed computer analyses including vectorial assessment of T waves of athletes would help clarify an ethnically specific range of normal for TWI. A further important consideration relates to the significance of the negative component of biphasic T waves. In athletes, TWI 1 mm in leads other than III, aVR, and V1/2 should lead to secondary evaluation. In athletes with biphasic T waves, it is recommend that considering the area contributed by the negative portion rather than considering depth below the isoelectric line until better classification is available. In some athletes TWI 1 mm in leads other than III, aVR, and V1/ should lead to secondary evaluation. In some athletes TWI after ST elevation in V2-V4 does not need investigation whereas inferior or lateral lead TWI warrants follow-up. In athletes with biphasic T waves, we recommend considering the area contributed by the negative portion rather than considering depth below the isoelectric line until better classification is available. Because TWI may be a harbinger of future disease, athletes with TWI whose imaging studies are negative (most likely 90%) should be followed annually with ECG and echocardiography. Cardiac MRI with gadolinium may be helpful in athletes with marked TWI in the inferior and lateral leads to rule out apical-variant HCM that may not be easily identified by echocardiography. Q-wave criteria for myocardial infarction according to the World Health Organization criteria is as 40 ms and amplitude 24% of the following R wave in 2 contiguous leads. Q waves in HCM appear to be caused by ventricular asymmetry, as demonstrated by magnetic resonance imaging (MRI). The best test characteristics for Q waves in HCM were found with 3 mm in depth and/or 40 ms duration in at least 2 leads. The Q waves of HCM most often are seen in the inferior and/or lateral leads.

(A 5-mm Q wave in a patient with hypertrophic cardiomyopathy. Note this is considered abnormal by ESC criteria and by our recommendation, but not by the R wave criterion) The high QRS voltage seen in both athletes and HCM patients, however, means that these criteria could lead to the identification of many more athletes than those based on 25% of the proceeding R wave alone. We recommend that HCM criteria for Q waves be used in young athletes (3 mm in depth and/or 40 ms duration in any lead except AVR, III, and V1). We do not endorse the use of standard coronary disease criteria for Q waves in young athletes, but they should apply in athletes 40 years of age.

:

Conclusion: The appropriate interpretation of the ECG in young athletes is challenging. In an attempt to standardize the interpretation of ECGs, minimize human error, and reduce the requirement for immediate interpreter expertise, some recommend computer-based algorithms for analysis of ECGs. One of the major limitations in this field is the absence of good data on the validity of specific ECG criteria. One area that has begun to be addressed is cost effectiveness. However, many other areas such as sport-specific differences in sudden death as well as sex and ethnicity-specific differences in the ECG and in sudden death rates remain poorly understood.

1. American Heart Association. Cardiovascular pre-participation screening of competitive athletes.

Med Sci Sports Exerc. 1996;28:144552.

2. Smith J, Laskowski ER. The preparticipation physical examination. Mayo Clin Proc. 1998;73:419 29.

3. Corrado D, Basso C, Schiavon M, Thiene G. Screening for hypertrophic cardiomyopathy in young athletes. N Engl J Med. 1998; 339: 3649.

4. Krowchuk DP. The preparticipation athletic examination: a closer look. Pediatr Ann. 1997; 26: 37 49.

5. Maron BJ, Shirani J, Poliac LC, Mathenge R, Roberts WC, Mueller FO. Sudden death in young competitive athletes. JAMA. 1996; 276: 199204.

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