Characteristics of the hormonal status and lipoprotein metabolism in patients with "coronary" type of behavior in the acute stage of myocardial infarction

The dissertation is devoted to the study of clinical-psychological and neuroendocrine characteristics in patients with "coronary" type of behavior in the acute stage of myocardial infarction. The work is aimed at identifying the interrelations between the psychological characteristics of patients, the character of the course of the disease, the development of complications, and the state of lipoprotein metabolism and hormonal status (the function of the hypothalamic–pituitary–thyroid and hypothalamic–pituitary–adrenal systems) in the acute period of myocardial infarction. The practical significance of the study is connected with the possibility of singling out a risk group with an unfavorable course of the disease and with the development of programs of complex correction, rehabilitation, and secondary prevention.

The study employed a comprehensive psychological examination, clinical-laboratory and instrumental methods of evaluating the course of myocardial infarction, as well as determination of the content of thyroid hormones, TSH, ACTH, and cortisol and parameters of lipoprotein metabolism, including the ratio of apolipoproteins apo-A1 and apo-B. The author has shown that in persons of "coronary" type of behavior transmural myocardial lesions and early complications are observed more frequently, along with a marked decrease in the level of thyroid hormones, an increase in thyrotropic function of the pituitary and in cortisol, and atherogenic shifts in lipoprotein metabolism.

Relevance of the work

In recent decades, myocardial infarction has continued to occupy a leading place among the diseases that determine high mortality and disability in the working-age population. This explains the attention paid to the study of the factors that determine the course and prognosis of this disease [145].

In recent years, considerable evidence has been obtained that psychological characteristics of the personality are independent predictors of the development of myocardial infarction, are of important pathogenetic significance, and should be considered together with such established risk factors as dyslipidemia, arterial hypertension, smoking, diabetes mellitus, and others [54, 66, 79, 145]. According to the literature, the frequency of occurrence of persons with a behavioral risk factor among patients who have suffered myocardial infarction amounts to 40–50% [21, 113, 115].

There are data on personality changes in patients who have suffered myocardial infarction and on disturbances of psychological adaptation in this group of patients [31, 103]. However, there are insufficient works devoted to the study of psychological characteristics and behavioral reactions with the aim of identifying premorbid personality traits of the patient and their influence on the development and course of cardiovascular diseases. It must be acknowledged that methods of objective assessment of psychophysiological status are used to a limited extent in clinical practice, which hinders the introduction into the practical activity of physicians of modern programs of psychotherapeutic and pharmacological correction in patients with coronary heart disease depending on their psychophysiological characteristics.

At the same time, at present insufficient attention is being given to questions of the response of the neuroendocrine system in coronary heart disease, in particular in its most severe manifestation—myocardial infarction. Certain investigators [70] have shown that in the acute stage of myocardial infarction diverse changes on the part of the endocrine system of the organism are observed. At the same time, some of them precede myocardial infarction, while others are its consequence and are capable of determining the character of the course of the disease and its outcome [12, 43].

At the present time, the problem of the influence of psychophysiological characteristics of the personality on hormonal and metabolic changes in myocardial infarction remains unstudied. Their investigation in the acute stage of myocardial infarction makes it possible to single out a group of "coronary" type of behavior with distinctive psychophysiological mechanisms of adaptation and to analyze the associated changes in the function of the hypothalamic–pituitary–thyroid and hypothalamic–pituitary–adrenal systems, as well as of lipoprotein metabolism under conditions of an acute vascular catastrophe. The identification of this category of patients makes it possible to assign them to a "risk" group with the aim of subsequently carrying out in timely fashion complex psychotherapeutic methods of correction.

Thus, this problem appears to us to be relevant both in the direction of studying the interrelation between psychological characteristics of the personality and the course of myocardial infarction, and in the direction of studying endocrine mechanisms of response and the characteristics of lipoprotein metabolism in patients with "coronary" type of behavior in the acute stage of myocardial infarction.

Aim of the study

To study the characteristics of the course of the acute stage of myocardial infarction, the frequency of development of complications, the hormonal status, and lipoprotein metabolism in patients with "coronary" type of behavior.

Objectives of the study

1. To single out and characterize a group of patients with "coronary" type of behavior in the acute stage of myocardial infarction on the basis of a comprehensive psychological examination.

2. To study the characteristics of the course of the acute stage of myocardial infarction and the frequency of development of complications in the group of patients with "coronary" type of behavior.

3. To evaluate the state of lipoprotein metabolism and the characteristics of the ratio of apolipoproteins (apo-A1 and apo-B proteins) in the acute stage of myocardial infarction depending on the psychological characteristics of the patients in the studied groups.

4. To determine the content of thyroid hormones, TSH, ACTH, and adrenal cortex hormones in the blood of patients in the acute stage of myocardial infarction, taking into account psychological characteristics.

Scientific novelty

It has been established that in persons of "coronary" type of behavior transmural lesions of the cardiac muscle predominate, with the associated more frequent development of such complications as acute left ventricular failure, early post-infarction angina, and also rhythm and conduction disturbances.

New data have been obtained on the hormonal response of patients in the acute stage of myocardial infarction depending on psychological characteristics. It has been shown that in patients of "coronary" type of behavior the course of myocardial infarction is accompanied by a marked decrease in the level of thyroid hormones, an increase in thyrotropic function of the pituitary, and an increase in the concentration of cortisol.

It has been revealed that the acute stage of myocardial infarction in persons of the "coronary" type of behavior group is accompanied by atherogenic shifts in lipoprotein metabolism.

Practical significance

The studied characteristics of the course of myocardial infarction, as well as the changes in certain endocrine indices and in lipoprotein metabolism in patients with "coronary" type of behavior, make it possible to detect in timely fashion patients with a prognostically unfavorable course of the disease. Singling them out into a separate group makes it possible to study in detail the optimal methods of correction of the revealed disturbances, as well as to create effective methods of rehabilitation and secondary prevention of the underlying disease.

Statements defended

1. In patients in the acute stage of myocardial infarction, whose principal psychological characteristics correspond to the category of "coronary" type of behavior, severe lesion of the cardiac muscle is noted, as well as the frequent development of early complications that aggravate the course of the disease.

2. Patients of "coronary" type of behavior are characterized by an atherogenic orientation of lipoprotein metabolism, as well as by changes in hormonal status marked by a decrease in thyroid function and an increase in the level of cortisol.

Approbation of the work

The main materials of the dissertation were presented at the international scientific-practical conference "Topical Questions of Clinical and Naval Medicine. Achievements, Prospects" (Sevastopol, November 2005); at a meeting of the Department of Military-Field (Naval) Therapy of the State Institute for Advanced Medical Training of the Ministry of Defense of the Russian Federation (Moscow, 2005); and at a meeting of the Academic Council of the Main Military Clinical Hospital named after N. N. Burdenko (22 March 2006).

Six scientific works have been published on the materials of the study, three of them in central press.

Implementation of the results of the investigation

The results of the investigation have been implemented in the clinical practice of the Main Military Clinical Hospital named after N. N. Burdenko and of the Clinical Hospital of the Medical Sanitary Unit of the Main Directorate of Internal Affairs of Moscow, and are used in teaching at the departments of cardiology and military-field (naval) therapy of the State Institute for Advanced Medical Training of the Ministry of Defense of the Russian Federation.

Structure and scope of the work

The dissertation is set out on 106 pages of typewritten text and consists of an introduction, 4 chapters, conclusions, practical recommendations, a list of references, and an appendix; it is illustrated with 15 tables and 18 figures. The list of references includes 167 sources: of them 86 domestic and 81 foreign authors.