The dissertation is devoted to the actual task of internal medicine – improvement in the detection of lipid metabolism disorders, insulin resistance (IR) and the state of the main arteries of the head in patients with CAD in combination with NALS and increasing the effectiveness of treatment of dyslipidemia in this category of patients on the basis of differentiated choice of medication.
The modern direction of the clinic of internal diseases development is the management of patients with comorbidities. Diagnosis and treatment of patients with coronary artery disease (CAD) in combination with non-alcoholic liver steatosis (NALS) continues to be one of the complex and unresolved problems of internal medicine. It was established that cardiovascular disease is the main cause of death of patients with NAFLD.
The dissertation was conducted in several directions. In the first part of the prospective study, a full clinical and instrumental examination of 81 patients with CAD was carried out. According to the study design, patients were divided into 2 groups: group 1 – patients with CAD in combination with NALS (n=61), group 2 (comparison group) – patients with CAD without NASP (n=20). Patients of the first group were divided depending on body mass index (BMI) per group with excess body weight (BMI 25-29.9 kg/m2), class 1 obesity (BMI 30-34.9 kg/m2) and class 2 obesity (BMI 35-39.9 kg/m2).
According to the results of the prospective analysis, it was found that the comorbid course of CAD and NALS in 95% accompanied by dyslipidemia. Reliably higher levels of leptin (by 87%) was detected in patients with CAD in combination with NALS, compared to a group of patients with CAD without NALS. 82% of patients with CAD and NALS had insulin resistance (IR). HOMA1-IR index in patients with 2 class obesity was 3.4 compared to the group of patients with 1 class obesity – 2.35 and overweight patients – 2.26, respectively. According to the results of ROC analysis of significant predictors of liver steatosis in the group of patients with CAD were levels of leptin, TG, BMI and waist circumference. TG level, BMI and waist circumference were significant predictors of IR by HOMA1-IR index.
The incidence of unstable atherosclerotic plaques of carotid arteries in the group with CAD and NALS was higher (34%) unlike patients with CAD without NALS (5%). Endothelial dysfunction was detected in 90% of patients with CAD and NALS, which is reliably higher than in patients without NALS 47% (p<0.05).
In the second part of the study, patients with CAD in combination with NALS were additionally divided into 3 groups, depending on the prescribed treatment.
After therapy with pitavastatin a moderate intensity of decrease in LDL (≥ 30%) in 60% of patients and high intensity (≥ 50%) – in 38% of patients was detected. Therapy with omega-3 polyunsaturated fatty acids contributes to the correction of dyslipidemia, namely the achievement of the target level of TG in 42% of patients. The use of UDCA contributes to a probable decrease in TG levels, LDL, VLDL, improves endothelial function without affecting insulin resistance indicators.
The novelty of the study and of the results. It was demonstrated that the combination of CAD and NALS is able to potentiate the imbalance in the lipid profile, significantly worsen the state of insulin resistance depending on BMI and have a negative impact on the development of endothelial dysfunction, increase the risk of atherosclerotic damage to the main vessels.
For the first time, the use of postprandial TG and leptin levels was proposed as additional markers for predicting the progression of atherosclerosis in CAD patients in combination with NALS, depending on BMI.
It has been shown for the first time that under the conditions of the combined course of CAD with liver steatosis, an increase in body weight is associated with a reduced reaction of postprandial TG levels with an increase in leptin levels and IR indicators.
The practical significance of the results. It is recommended to patients with CAD: stable angina 2-3 FC to conduct mandatory examination: liver ultrasound, determination of ALT, AST in order to detect NALS. The importance of evaluation of postprandial triglycerides and leptin levels in patients with CAD in combination with NALS was demonstrated. It was found that the appointment of low doses of pitavastatin (2 mg per day) is recommended for patients with CAD and NALS in the presence of intolerance to statins in the history. The use of alternative therapy of omega-3 polyunsaturated fatty acids (eicosapentaenoic and docosahexaenoic acid) at a dose of 2000 mg per day is recommended if statins cannot be prescribed. Therapy with ursodeoxicicholic acid at a dose of 10 mg/kg of body weight can be considered as an addition to the main therapy for CAD.
Key words: coronary artery disease, nonalcoholic liver steatosis, state of the main arteries of the head, lipid metabolism, insulin resistance.
