Резюме
Панченко М.С. Медико-психологічні, санологічні та генеалогічні передумови формування підвищеного серцево-судинного ризику у пацієнтів з хронічними захворюваннями шлунково-кишкового тракту.
Досліджено частоту окремих факторів кардіоваскулярного ризику у хворих на хронічні захворювання шлунково-кишкового тракту, визначена їх діагностична інформативність та прогностичне значення, опрацьовано алгоритм оцінки факторів ризику.
Ключові слова: кардіоваскулярний ризик, медико-психологічні, генеалогічні фактори.
Резюме
Панченко Н.С. Медико-психологические, санологические и генеалогические предпосылки формирования повышенного сердечно-сосудистого риска у пациентов с хроническими заболеваниями желудочно-кишечного тракта.
Изучена частота отдельных факторов сердечно-сосудистого риска у больных с хроничекими заболеваниясми желудочно-кишечного тракта, определены их диагностическая информативность и прогностическая значимость, разработан алгоритм оценки факторов риска.
Ключевые слова: кардиоваскулярный риск, медико-психологиские, генеалогические факторы.
Summary
Panchenko M.S. Medical, psychological, and genealogical prerequisites for the formation of increased cardiovascular risk in patients with chronic diseases of gastrointestinal tract.
The frequency of the individual factors of cardiovascular risk in patients with chronic diseases of gastrointestinal tract was studied, their diagnostic information and predictive value were identified, the algorithm of risk assessment was created.
Key words: cardiovascular risk, medical psychology, genealogical factors.
Рецензент: д.мед.н., проф. В.О. Тєрьошин

УДК 616.33-002.43:616.62-003.4

Харківська медична академія післядипломної освіти МОЗ України

Харьковская медицинская академия последипломного образования

Kharkov medical academy of Postgraduate Education

serg_shklyar@ukr.net

Introduction. Health problems of the population called as one of the priorities of WHO in twentieth century.  Current efforts of the European medical community are directed to solve the negative trends in declining health due to the influence of social, environmental and other problems, particularly in reducing cardiovascular risk (CVR) [7]. The rising time of temporary disability and primary disability as a result of chronic diseases, including combined, inflicts substantial economic losses and increases the social value of researches aimed to improve medical and psychological monitoring, early diagnosis, individualized treatment, and risk-measuring approaches [2].

In the structure of gastro - intestinal tract a leading position (35.7%) occupies the gallbladder and ducts diseases - each year 294 new cases per 10 thousand of the adult population [8]. Functional disorders of the gastrointestinal tract and the formation of nosological-defined conditions are considered as stages of a single pathological process, and success in fighting with them gears to the active detection and elimination of risk factors and improving diagnosis and treatment of early stages of the disease [1]. At the beginning of 2007, according to the WHO Expert Committee and European Society of Hypertension and European Society of Cardiology Guidelines Committee in almost 20,0% of adults a high blood pressure was identified, and in old age - in 40-60%. Mortality from cardiovascular diseases has increased by more than 60,0% [4]. According to the World Health Report (2002), one-third of deaths from cardiovascular events is associated with 10 key risk factors, including high cholesterol - for 4.4 million cases, smoking - 4.9 million, increased blood pressure (BP) – 7,1 million. Given that 30% of population are obese, the likelihood of arterial hypertension (AH) in this case is increased by 50% in the presence of each 4.5 kg of excess body weight the systolic blood pressure increases in 4.4 mm Hg. in men and by 4.2 mm Hg. - in women. When body mass index (BMI) is in the range 25-28,9 kg/m², the risk of coronary heart disease (CHD) is doubled, with a BMI >29 kg/m² – is tripled. This relationship is a proven risk factor [5].

A study of pathogenetic role, diagnostic value and prognostic value of type dyslipidemia in patients with chronic diseases of the gastrointestinal tract (CD GIT) is required; complexity and multifactorial of these interactions may determine the course of pathological process and prognosis of the patient [6].

Thus, the high prevalence of risk factors in the population indicates unfavorable epidemiological situation of cardiovascular diseases in the population of Ukraine. The presence of such risk profile can`t make an expectation of a marked decrease in mortality in near term, and demonstrates the need for more active use of medical and psychological impact methods on population, family and individual levels, which requires study of the diagnostic informativeness and prognostic values of a number risk factors.

The aim of the study was to explore the diagnostic and prognostic value of individual cardiovascular risk factors in patients with CD GIT.

Materials and methods. Primary information base for the implementation of research was the result of complex clinical - anamnestic examination of young patients (32,6 ± 3,9 y.) With CD GIT, including 84 patients with elevated CVR (first group), determined by the «SCORE» method [2, 7] and 84 patients without CVR (second group) groups weren`t separated by age and sex. Research was conducted by a standardized program of collection, storage and analysis of results. In particular, analysis of distribution of individual factors in the two groups of patients allowed, from the standpoint of evidence-based medicine and the use of modern methods of clinical and statistical analysis (variance, correlation analysis) and forecasting methods (serial analysis of Wald in modification of E.V.Gubler), determine a diagnostic value (I₂, bit), predictive value and impact of factors on the performance difference of two compared groups (η², %) and prognostic factors (PF, pat) [3] in order to justify the CVR indicators in patients with gastrointestinal CD GIT the above quantitative characteristics factors were  applied. The data on the informativeness of risk factors, allowed to process information model of CVR formation process and tabular algorithm for its evaluation in patients with CD GIT, is presented.

Results and theQI discussion. Key feature (frequency, diagnostic and prognostic value) to physique-biological and genealogical factors of CVR at CD GIT investigated for theQI comparative analysis among the patients in two groups. Among physique-biological factors of CVR also the following parameters were investigated: the constitutional type of patient, the presence of somatotype anomalies and auricles` anomalies and Quetelet index, waist circumference and hip with the definition of the waist / hip ratio. Among genealogical factors against the influence of chronic diseases of the gastrointestinal tract (CD GIT), clinically equivalent of nonspecific resistance decrease (frequent SARS) and dismetabolic pathology of bone - the muscular system (BMS).

Constitutional type and CVR at CD GIT. Influence of constitutional features of patients to relative CVR was investigated and found that the level of CVR in patients with CD GIT not depend on body type (η² = 1,0%, p = 0,303) and the proportion of different constitutional types in the two groups is the same: hypersthenic (Group 1 - (46,9 ± 4,2)%, group 2 - (46,8 ± 4,7)%), normostenic respectively (19,6 ± 3, 3)% and (23,4 ± 4,0)%, and asthenic - (33,6 ± 3,9)% and (29,7 ± 4,3)%, respectively.

It should be noted that, unlike the constitutional type, significant factor of CVR at CD GIT is the presence of somatotype anomalies. The frequency of this factor in the first group is (23,8 ± 3,6)%, in the second - (8,1 ± 2,6), which defines the information content (I = 0,403) and impact strength (η² = 4,0 %) of factor and its prognostic value; the presence of somatotype anomalies increases in 4,7 times relative CVR in a patient with CD GIT, a prognostic factor is: ⁺PF = 4,7 in the presence of such anomalies and ^-PF = -1,0 in its absence. Patients with high CVR had a greater frequency (p = 0,003) of such embryogenesis stigmas as anomalies of auricles (the first group made ​​the QI frequency (20,3 ± 3,4)%, the second - (7,2 ± 2,5)%), which requires consideration in CVR system prediction.

The study of the prognostic value of Quetelet index showed that among patients with CVR at CD GIT significantly (p <0,001) were less than those with QI <25 (36,4 ± 4,0)% and (71,2 ± 4,3 )%, while those with higher values ​​of QI were more precisely in patients with CVR (11,2 ± 2,6)% and (2,7 ± 1,5)%, respectively (p <0,01). Informative (I = 1,168) and impact strength (η ² = 12,0%) factor determining its prognostic value in the presence of QI> 29,9 increases relative CVR in patients with CD GIT, and a prognostic factor is: PF = 6 ⁺ 2 whereas at QI <25 ^- PF = - 2.9, and the relative risk decreased threefold.

In the study of the prognostic value of the indicator "waist circumference" determined that its growth (more than 102 men, 0 cm in women over 88, 0 cm) occurred significantly more often in CD GIT in patients with CWR, respectively (39,2 ± 4 1)% and (23,4 ± 4,0)% of patients. Informational (I = 0 255) and impact strength (η ² = 2.0%) factor determining its predictive value; the excess referred to "sexual norms" increases relative CVR in a patient with CD GIT, a prognostic factor is: ⁺PF = +2,2, whereas the normal value is ^-PF = -1.0, and the relative risk decreased threefold. In order to find a more informative criteria in comparing groups of patients with CD GIT, calculation of circumference indicator "waist / hip" was performed ("norm" for men - 0.95 for women - 0.8) and was revealed that among people in the first group (75,5 ± 3,6)% had an excess of these "rules", and the second - in (26,1 ± 4,2)%. Informational (I = 1, 324) and impact strength (η ² = 24.0%) factor and its prognostic significance are the largest; increase of this figure is almost an order of magnitude increases relative CVR in a patient with CD GIT. In exceeding of the "normal" value a prognostic factor is: ⁺ PF = 4.6, and in the case of "normal values" forecasting coefficient is ^- PF = -4.8.

Incidence of CVD at mother, as revealed by the results of the comparative analysis is correct (p <0.001) factor affecting the increase of CVR at CD GIT. Thus, in the first group in the frequency of family history of CVD was (29,4 ± 3,8)%, while the second is almost three times less - (7,2 ± 2,5)%, which defines the information content (I = 0.806) and force of impact (η ² = 7.0%) factor and its prognostic value in the presence of cardiovascular disease in the mother in 4,1 times increases relative CVR in a patient with CD GIT, and a prognostic factor is: ⁺ PF = 6.1 in the presence of hereditary predisposition and ^- PF = -1.2 in its absence.

Incidence of CVD at father, as revealed by the results of the comparative analysis are significant (p <0.005) factor affecting the increase in CVR CD GIT. Thus, in the first group in the frequency of family history of CVD was (25,9 ± 3,7)%, while the second is almost twice less - (11,7 ± ​​3,1)%, which defines the information content (I = 0.298) and force of impact (η ² = 3.0%) factor and its prognostic value in the presence of CVD father in 2, 2-times increases relative CVR in a patient with CD GIT as a prognostic factor is: ⁺ PF = 3, 4 in the presence of hereditary predisposition and ^- PF = - 0, 8 in its absence.

Incidence of CVD, at least at one of the parents, as revealed by the results of the comparative analysis is a significant (p <0.0001) factor affecting the increase in CVR CD GIT. Thus, in the first group in the frequency of family history of CVD was (55,2 ± 4,2)%, while the second is almost twice less - (18,9 ± 3,7)%, which defines the information content (I = 1, 314 ) and impact strength (η ² = 13.0%) factor, and also of prognostic value of the presence of CVD in one of the parents is more than 3.1 times the relative increases in patients with CVR CD GIT as a prognostic factor is: ⁺ PF = 4.6 in the presence of hereditary predisposition and ^- PF = -2.6 in its absence.

Frequency of CD GIT at mother, as revealed by the results of the comparative analysis is a significant (p <0.001) factor affecting the increase of CVR CD GIT. Thus, in the first group in the frequency of family history was CD GIT (39,9 ± 4,1)%, while the second is almost three times less - (13,5 ± 3,2)%, which defines the information content (I = 0.827) and force of impact (η ² = 8.0%) factor and its prognostic value; the presence of the CD GIT at mother in almost threefold increases relative CVR in a patient from DB and prognostic factor is: ⁺ PF = 4.6 in the presence of hereditary predisposition and ^- PF = -1.6 in its absence.

Frequency CD GIT at father, as revealed by the results of the comparative analysis is significant (p <0.015) factor affecting the increase of CVR at CD GIT. Thus, in the first group in the frequency of family history was CD GIT (18,9 ± 3,3)%, while the second - 2,3 times smaller - (8,1 ± 2,6)%, which defines the information content (and = 0.227) and impact strength (η ² = 2.0%) factor and its prognostic value in the presence CD GIT father in almost an order of magnitude increases relative CVR in a patient with CD GIT, a prognostic factor is: ⁺ PF = 3, 5 in the presence of hereditary predisposition and ^- PF = -0.5 in its absence.

Frequency CD GIT at one of the parents, as revealed by the results of the comparative analysis is significant (p <0.0001) factor affecting the increase in CVR CD GIT. Thus, in group 1 frequency family history for CVD was (58,7 ± 4,1)%, while in the 2nd - almost twice less - (21,6 ± 3,9)%, which defines the information content ( I = 1, 323) and impact strength (η ² = 14.0%) factor, and its value; CD GIT presence in one of the parents is more than 2.6 times increases relative CVR as a prognostic factor is: = ⁺ PF 4.3 in the presence of hereditary predisposition and ^- PF = -2.8 in its absence.

Among the patients of the first group SARS was significantly (p <0.005) more frequent (26,2 ± 3,7)%, while in the second - (10,8 ± 2,9); presence of this factor considered by us as the clinical equivalent of nonspecific resistance reduction and determined that the existence of frequent SARS more than 3-times increases relative CVR in a patient with CD GIT, a prognostic factor is: ⁺ PF = 3.8 in the presence and ^- PF = -1.0 in the absence of a history frequent SARS. The presence in parents of surveyed patients a dismetabolic disease mainly affecting the skeletal system is registered with a frequency of (20,3 ± 3,4)% - in the first group and among (9,0 ± 2,7)% - in the second (p <0.013); CVR associated with this genealogical factor almost 5 times higher, and the force of impact of this factor is (η ² = 2.0%), a prognostic factor is: ⁺ PF = 3.5 in the presence of hereditary predisposition and ^- = PF -0.6 when it is absent.

According to a study of the frequency of certain genealogical and physique-biological factors using a standardized procedure for determining the diagnostic value and prognostic significance of each factor a prediction algorithm of CVR in patients with CD GIT has worked. Structurally, the algorithm has a table that includes measurement indicators, prognostic factors (PF) and the scale of assessment outcome prediction. Principles of forecasting are based on consistent recognition procedure using tabular algorithm criteria for which are the most informative and meaningful ones.

For each indicator determine its presence or absence, and the corresponding pathological measurement coefficients added. Upon reaching threshold coefficient (- 13 or 13), using a scale the CVR was determined. Only independent features forecasting was made to the algorithm. Where the strength of correlation (± r _xy) between factors was greater than ± 0,70, then one of the factors excluded from the list of indicators. The use of tabular algorithm implements pathological measurement approach to CVR risk assessment. Algorithm takes into account not only existing indicators, but also minimizes the number of steps of predictive technology through the use of the most informative criteria of CVR in patients of CD GIT.

Conclusions.

1. The frequency of certain constitutional and biological and genealogical cardiovascular risk factors in patients with CD GIT was investigated and it was determined, that the most influential constitutional and biological indicators of risk are: the index value of "waist / hip" and Quetelet index, among genealogy - hereditary predisposition in CVD and CD GIT.

2. The diagnostic information content of the studied factors and their predictive value and might influence in the formation of cardiovascular risk in patients with CD GIT.

3. A family doctor algorithm for monitoring the CVR level, that consider identified in the study are informative indicators in CD GIT patients, was worked out.

Prospects for further research on the issue related to need of further exploring the clinical anamnesis, personal and behavioral factors in patients with CVR CD GIT and also exploring common mechanisms for the implementation of the risk of medical and psychological impacts.

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