Diyabetik hastalarda sessiz miyokardiyal iskeminın egzersiz elektrokardiyografisi ile araştırılması
Research of diabetic patients who have myocardial silent i̇schema with exersiz ECG
Yazar: MOHAMMAD TOIB AMERI
Danışman: PROF. DR. ZERRİN YİĞİT
İstanbul Üniversitesi-Cerrahpaşa / Lisansüstü Eğitim Enstitüsü / Kardiyoloji Ana Bilim Dalı / Fizyoterapi ve Rehabilitasyon Bilim Dalı
Derece: Doktora, 2019
Konu: Göğüs Hastalıkları = Chest Diseases ; Kardiyoloji = Cardiology
Dizin: Diabetes mellitus = Diabetes mellitus ; Diabetes mellitus-deneysel = Diabetes mellitus-experimental ; Diabetes mellitus-tip 1 = Diabetes mellitus-type 1 ; Diabetes mellitus-tip 2 = Diabetes mellitus-type 2 ; Hipertansiyon = Hypertension ; Kardiyovasküler hastalıklar = Cardiovascular diseases ; Kardiyovasküler sistem = Cardiovascular system ; Koroner arter hastalığı = Coronary artery disease ; Pulmoner kalp hastalığı = Pulmonary heart disease

Özet:
Diyabetik Hastalarda Sessiz Miyokardiyal İskeminin Egzersiz EKGsi ile Araştırılması. İstanbul Üniversitesi-Cerrahpaşa Lisansüstü Eğitim Enstitüsü, Kardyolojı ABD.Doktora Tezi. İstanbul Mehmet Akif Ersoy göğüs Kalp ve Damar Cerrah i eğitim ve Araştıram Hastanesi. Bu çalışma, 2016 – 2019 tarihleri arasında İstanbul Mehmet Akif kalp damar  Eğitim ve Araştırma Hastanesi Polikliniği'ne başvuran hastalar arasından seçilen 500 hasta üzerinde ypılış olan hastalarda yapıldı.
Anahtar Kelimeler: Diabetes mellitus(DM), Egzersiz EKG testi, Sessiz Myokardiyal İskemi(SMİ), Myokard Perfüzyon Scintigrafisi(MPS), Vücut kitle indeksi(VKİ)
Koroner kalp hastalığı (KKH).
Bu çalışma, İstanbul İstanbul Mehmet Akif Ersoy göğüs Kalp ve Damar Cerrah i eğitim ve Araştıram Hastanesi  tarafından desteklenmiştir. Proje No:947 .
Normal hastalarla ilişkili DM hastalarında Kronor Arter Hastalığı (CAD) riski daha yüksektir. Ayrıca, diyabetik hastalarda KAH prognozu DM olmayan hastalara göre daha kötüdür ve kısa ve uzun vadede diyabet hastaları için daha yüksek mortalite oranına yol açtığından Miyokard İnfarktüsü (MI) süreci daha ciddidir. Bu sayfa Sessiz Miyokard İskemisinin (SMI) erken tanısı altında prognoz altında çok önemlidir. İpucu II DM'de SMI insidansı normal popülasyondan daha yüksektir. Bu vakalarda, diyabetik kardiyonöropati nedeniyle göğüs ağrısı tespit edilemez.
Bilinen bir koroner arter hastalığı yoktu; Çalışmaya adım değirmeni veya dinlenme dispnesi ve nefes darlığı tanımlamayan 500 diyabetik hasta dahil edildi. Hastalar Mehmet Akif Eğitim ve Araştırma Hastanesi Polikliniği'nde takip edildi. 161 hasta erkek ve 339 kadındı; Yaşları 37-70 arasında değişiyordu. Dental değirmen grubunda yaş ortalaması 53.61 ± 7.86, miyokard perfüzyon sintigrafisi (TC.99 Mibi) grubunda 57.13 ± 8.09 idi.
Çalışmamızın amacı; Diyabetik veriler, SMI saptamak için iki testin etkinliğini karşılaştırmak ve birbirlerini karşılaştırmaktı. Egzersiz sonuçları egzersiz testi yapılan 356 hastanın 144'ünde ve miyokard perfüzyon sintigrafisi uygulanan 144 hastanın 40'ında pozitifti. SMI'yi doğrulamak için koroner anjiyografi yapıldı. Koroner anjiyografide, herhangi bir koroner arterin% 70 veya daha fazla stenozu KAH için kriter olarak kabul edildi. Pozitif egzersiz testi olan 76 hastaya koroner anjiyografi yapıldı. Anjiyografide 60 tek damar ve yan dal hastalığı, 11 anlamlı olmayan damar hastalığı ve 533 damar hastalığı saptandı. Sonuç olarak 60 hastaya PTCA + stent, 5 hastaya Koroner Arter Bypass Greftleme (KABG) uygulandı. Koroner arter darlığı olan hastalarda% 30 ile% 60 arasında yoğun tıbbi tedavi önerildi. Miyokard perfüzyon sintigrafisinde (MPS) 40 pozitif MPS ve 104 ilişkili negatif MPS vardı. Kırk MPS pozitif hastaya koroner anjiyografi yapıldı. Anjiyografi ve tıbbi takip için 15 tek damar ve yan dal hastalığı, 25 koroner anjiyografi (CAG) uygulayıcısı ve koroner anjiyografi (CAG) talep etmediler.
SMI insidansı% 15.2 iken, SMI insidansı (kritik olmayan stenozu olan hastalar dahil); % 12'de SMI insidansı ve önemli koroner anjiyografisi olan hastalarda% 2.2 koroner anjiyografi ve% 1 koroner anjiyografide anlamlı bir hasat görülmedi.
Miyokard Perfüzyon Sintigrafisi (MPS), SMI insidansı% 8 iken, SMI insidansı (anlamlı olmayan darlığı olan hastalar dahil); SMI insidansı% 5 koroner anjiyografide ve% 5 koroner anjiyografide anlamlı idi.
Doğru ve pozitif, noninvaziv testler (birlikte yaşama ve talyum grubu hastalar) SMI için pozitif ve negatif olarak saptandı ve koroner anjiyografi olarak SMI kullanıldı. Grup seks yok, hipertansiyon sıklığı; Yaş, diyabet süresi, toplam kolesterol, trigliserit ve lipit profili arasında korelasyon yoktu (p <0.05), bu da egzersiz grubundan anlamlı olarak yüksekti (p> 0.05).
Sonuç olarak, SMI tanısı için çaba testinde ve talyum miyokard perfüzyon sintigrafisinde üstünlüğü belirleyemedik.

Abstract:
Research of Diabetic Patients who have Myocardial Silent İschema with Exersiz ECG. İstanbul University-Cerrahpasa, Institute of Graduate Studies, Department of Cardiology. Doktora Thesis  did completed in İstanbul Mehmet Akif Ersoy Cardiovascular  Surgery Educational and Reaserach Hospital. 
This Research has completed in the duration of 2016 – 2019  in İstanbul Mehmet Akif Ersoy Cardiovascular  Surgery Educational and Reaserach Hospital.The research was done by completed 500 patients whose are examine  and polyclinc. 
Key Words: diabetes mellitus, Egsercise EKG Test(EET), Myocard Perfussion Scintigraphy(MPS), Silent Myocardial Ischemia(SMI), Coronary Heart Disease(CHD), Body Mass Index (BMI)
The present work was supported by the Research Fund of İstanbul Mehmet Akif Ersoy Cardiovascular  Surgery Educational and Reaserach Hospital. Project No. 947  
The coronary artery diseases,  is one of complication of the macrovascular  of DM developing in association with the atherosclerosis, is the primary cause for DM associated death. It is more common in the DM patients. Furthermore, the prognosis of CAD is worse  in diabetic patients, when compared to the patients without Diabetes Mellitus, and occurance of  MI is more serious in diabetics because of it causes high mortalities in the short and long term. Because of that, early examine and diagnosis of SMI is important as for the prognosis of patients. In these cases, chest pain due to diabetic cardio neuropathy is not apparent.
 500 diabetic patients, who had no known coronary artery diseases(CAD), or not express  rest dyspnea or dyspnea were included in the study. The patients were followed in Mehmet Akif Cardiovascular educational and research Hospitals´ Polyclinics. 161 of the patients were male, 339 were female, between the ages of 37 and 70. The average age was 53,61±7,86 in the effort group, 57,13±8,09 .
The goal of this study was to assess the efficiency of the two tests in diabetic patients and compare the tests to each other. 356 of the 76 patients subjected to effort tests, and 144 of the  patients subjected to Myocard Perfussıon  scintigraphy(TC.99 Mibi) revealed 40 patients were positive for  test results  . 
The patients, whose test results were positive, they have done coronary angiography so that Silent Myocardial Ischemia (SMI) was verified. In the coronary angiography, determination of 70% or over constriction in a coronary artery was assumed as a requirement for CAD criteria. 
76 of the 40 patients with positive effort test,were performed Kroner Angio graphy(KAG) and had critic lesions (meaningsful lessions) and implemented Percutanouse Transluminal Coronary Angioplasty (PTCA) and Stents.The 11 patients were had not critic lesions(not had meaningful lessions) and adviced Medical follow up. The 5 patients had Mullti coronary artery lessions and had indications for Coronary Artery Bypass  CABG and did Coranary Artery Bypass Grafting(CABG). 
 Myocard Perfussion scintigraphy(MPS) was positive, from 144 of the 40 patients with positive Myocard perfussion scintigraphy revealed  Silent Myocard Ischemai (SMI) compliant coronary angiography. After coronary angiography, 15 patient with positive MPS test was applied a stent, 25 patient were some of them have contraindication for KAG and some of them did not want KAG and some of them had not meaningful lession for KAG.  And adviced Medical follow up and treatment were advised.  
Accordingly, in our study, the SMI frequency determined by non-invasive positive tests                 ( Myocard perfussion Scintigraphy) was 8% in the group subjected for Koronary Angiography(KAG) from these 8% positive MPS test were had 3% meaningful lessions(critic lessions ) and implemented PTCA and Stent.And other 5% patients had contraindications for KAG , some of them had not meaningful lessions and some of the patiens did not wanted to perform Coronary Angiogrphy (KAG).
 Treadmill ,Efor positive test, 15.2% in the group subjected to Myocard KAG and 12% patients had meaningful lessions and implemented PTCA and Stent, 2.2% patients had not meaningful lessions and advised medical follow up. The remaing 1% patients had multi vessels coronary arteries meaningful critic lessions and  did Coronary Artery Bypass Grafting(CABG).  
  Hence, the false positiveness ratio of the effort test is 50.0% while that of the Miyocard perfussion scintigraphy is 14.3%, the positive predictive value of the effort test is 50.0%, and that of the thallium scintigraphy is 85.7%.
The patients were compared in such classifications as having negative or positive effort tests, these were found for positive or negative through noninvasive tests (effort and Myocard perfussion Scintigraphy group patients together), the ones which are verified to be or not to be SMI by coronary angiography (CAG). In none of the compared group, a relation was found between SMI and sex, history of family, history of smoking, frequency of hypertension, age, height, weight,Body Mass Index (BMI), diabetes period, HbA1c, Acute Coronary Syndrome(ACS), Total Cholesterol, triglyceride and creatinine averages (p<0.05).
 But in the thallium group, Oral Anti Daibetic(OAD) plus insulin usage frequency, age and value of urea averages was significantly high in comparison to effort group (p>0,.05).
As a result, we could not verify the statistical dominance of the effort test to thallium myocardial perfusion scintigraphy (MPS) for the purpose of SMI diagnosis. In such a case, the easily available and cost efficient ECG test could be considered as a better choice for SMI confirmation. But from the numerical point of observation, we could be clever to diagnose more patients with SMI using thallium scintigraphy(MPS) and found much higher positive prophetic value of the thallium test in comparison to the effort test. When the number of patients have been increased, we believe that thallium scintigraphy could be seen better  and superiority to the effort test from statistical point. According to our study, CAD does not have a relation with any factor, but when the number of patients have been increased, we consider that, literature compliant findings could be obtained.