rspНаучно-практическая ревматологияRheumatology Science and Practice1995-44841995-4492IMA-PRESS, LLC10.14412/1995-4484-2015-51-57rsp-2038Research ArticleОРИГИНАЛЬНЫЕ ИССЛЕДОВАНИЯORIGINAL RESEARCHВозможности эхокардиографического определения давления в легочной артерии у пациентов с системными заболеваниями соединительной ткани: данные ревматологического экспертного центраPOSSIBILITIES FOR ECHOCARDIOGRAPHIC DETERMINATION OF PULMONARY ARTERY PRESSURE IN PATIENTS WITH SYSTEMIC CONNECTIVE TISSUE DISEASES: DATA OF A RHEUMATOLOGY EXPERT CENTERНиколаеваЕ. В.NikolaevaE. V.КорсаковаЮ. О.KorsakovaYu. O.КурмуковИ. А.KurmukovI. A.ГлуховаС. И.GlukhovaS. I.ЮдкинаН. Н.YudkinaN. N.ВолковА. В.VolkovA. V.sandyvlk@yahoo.comФГБНУ Научно- исследовательский институт ревматологии им. В.А. Насоновой, Москва, Россия 115522 Москва, Каширское шоссе, 34АРоссияV.A. Nasonova Research Institute of Rheumatology, Moscow, Russia 34A, Kashirskoe Shosse, Moscow 115522Russian Federation2015120320155315157Copyright © Николаева Е.В., Корсакова Ю.О., Курмуков И.А., Глухова С.И., Юдкина Н.Н., Волков А.В., 20152015Николаева Е.В., Корсакова Ю.О., Курмуков И.А., Глухова С.И., Юдкина Н.Н., Волков А.В.Nikolaeva E.V., Korsakova Y.O., Kurmukov I.A., Glukhova S.I., Yudkina N.N., Volkov A.V.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://rsp.mediar-press.net/rsp/article/view/2038

Цель исследования – оценить достоверность неинвазивной оценки давления в легочной артерии (ДЛА) методом допплеровской эхокардиографии (ЭхоКГ) в сравнении с инвазивными измерениями этого параметра у пациентов с системными заболеваниями соединительной ткани (СТЗСТ). Материал и методы. Были проанализированы инвазивно измеренные показатели гемодинамики в сравнении с аналогичными параметрами, вычисленными при ЭхоКГ. В анализ включено 156 парных исследований 61 больного с легочной гипертензией (ЛГ) на фоне СТЗСТ и 26 пациентов, у которых ЛГ при катетеризации не подтверждена. У 45 пациентов была выявлена легочная артериальная гипертензия (ЛАГ), у 7 ЛГ была обусловлена поражением левых отделов сердца, у 9 – гипоксемией.Результаты и обсуждение. Систолическое давление в легочной артерии (СДЛА), измеренное методом ЭхоКГ, составляло в среднем 72,4±33,7 мм рт. ст., а при катетеризации правых отделов сердца – 63,3±25,1 мм рт. ст. Корреляция значений этого показателя, полученного двумя методами, была высоко достоверной – r=0,83 (р<0,00001). Давление в правом предсердии (ДПП) составило 8,4±4,1 мм рт. ст. при ЭхоКГ и 6,7±5,2 мм рт. ст. при катетеризации. Корреляция ДПП по данным ЭхоКГ и катетеризации была высоко достоверной – r=0,57 (p<0,0001). 

Несмотря на высокие коэффициенты корреляции, у 7 пациентов с ЛГ, верифицированной при катетеризации, ЭхоКГ не позволила обнаружить повышение СДЛА; ложноположительные результаты отсутствовали. ЭхоКГ продемонстрировала хорошие чувствительность (94%) и специфичность (100%) для порогового СДЛА 40,1 мм рт. ст. (площадь под кривой 0,99; р<0,0001; 95% ДИ 0,98–1,01). Эхокардиографическое определение ДПП по существующим методикам показало хорошие чувствительность (79%) и специфичность (69%) для порогового значения ДПП 5 мм рт. ст. (площадь под кривой 0,79; р<0,0001; 95% ДИ 0,70–0,95). 

У пациентов с низким уровнем среднего ДЛА (СрДЛА) по данным катетеризации расхождение показателей по ЭхоКГ >10 мм рт. ст. отмечалось в 5% случаев, а расхождений >20 мм рт. ст. не отмечено. У больных с высоким уровнем СрДЛА расхождение показателей >10 мм рт. ст. отмечалось в 28,9% случаев, а >20 мм рт. ст. – в 34,2%. 

Анализ согласия Блэнда–Альтмана показал отклонение +8,22 мм рт. ст. для СДЛА (95% ДИ 6,6–12,8) и +1,56 мм рт. ст. для ДПП (95%ДИ 0,85–2,27). Стандартное отклонение разностей составило 18,4 для СДЛА и 4,5 для ДПП. Обнаружена зависимость разностей показателей от среднего их значения, более значимая для СДЛА. Коэффициент корреляции для СДЛА составил 0,43 (р<0,001), для ДПП – 0,31 (p<0,05). Таким образом, анализ Блэнда–Альтмана выявил систематическое расхождение, что свидетельствует о слабой степени согласования результатов двух методов определения СДЛА и ДПП. Заключение. По результатам нашего исследования, ЭхоКГ оказалась надежным методом скрининга ЛГ у пациентов с СТЗСТ. Для более точного определения СДЛА и ДПП необходимо применять инвазивные методы диагностики.

Objective

Objective: to assess the significance of noninvasive estimation of pulmonary artery pressure (PAP) using Doppler echocardiography (echoCG) as compared to invasive measurements of this parameter in patients with systemic connective tissue diseases (SCTD). Subjects and methods. The invasively measured hemodynamic parameters versus those estimated at echoCG were analyzed. The analysis included 156 paired studies of 61 patients with pulmonary hypertension (PH) in the presence of SCTD and 26 patients, in whom PH was not verified by catheterization. Forty-five patients were found to have PH; PH was caused by left heart involvement in 7 patients and by hypoxemia in 9. Results and discussion. Systolic PAP (SPAP) measured by echoCG averaged 72.4±33.7 mm Hg and that by right heart catheterization did 63.3±25.1 mm Hg. The correlation of the values of this measure, which were obtained by the two methods, was highly significant (r = 0.83; p < 0.00001). Right atrial pressure (RAP) measured by echoCG and catheterization was 8.4±4.1 and 6.7±5.2 mm Hg, respectively. The echoCG and catheterization RAP correlation was highly significant (r = 0.57; p < 0.0001). 

Despite the high correlation coefficients, echoCG failed to detect higher SPAP in 7 patients with PH verified by catheterization; EchoCG could not detect higher SPAP; false-positive results were absent. EchoCG demonstrated good sensitivity (94%) and specificity (100%) for a threshold SPAP of 40.1 mm Hg (the area under the curve was 0.99 (p < 0.0001) with 95% CI 0.98–1.01. The echoCG determination of RAP by the existing methods showed good sensitivity (79%) and specificity (69%) for its threshold of 5 mm Hg (the area under the curve was 0.79 (p < 0.0001) with 95% CI 0.70–0.95. 

The patients with low level of mean PAP (PAPmean) measured by catheterization showed a difference of > 10 mm Hg as compared with the echoCG levels in 5% of the cases; > 20 mm Hg discrepancy was not noted. In patients with high PAPmean, the differences of > 10 and > 20 mm Hg were observed in 28.9 and 34.2% of the cases, respectively. Analysis of the Bland–Altman agreement showed deviations of +8.22 mm Hg for SPAP (95% CI 6.6–12.8) and +1.56 mm Hg for RAP (95% CI 0.85–2.27). The standard deviation of differences was 18.4 for SPAP and 4.5 for RAP. There was a relationship between the differences from their mean value, which is more significant for SPAP. The correlation coefficient for SPAP was 0.43 (p < 0.001) and that for RAP was 0.31 (p < 0.05). Thus, the Bland–Altman analysis revealed a systematic disparity, suggesting a weak agreement of the results of the two methods determining SPAP and RAP. 

Conclusion

Conclusion. Our investigation demonstrated that echoCG proved to be a valid and reliable screening method for PH in patients with SCTD. More accurate estimation of SPAP and RAP measurement requires the application of invasive diagnostic methods.

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The authors declare that there are no conflicts of interest present.