В обзоре представлены данные литературы по проблеме коморбидности хронической обструктивной болезни легких (ХОБЛ) и цереброваскулярных заболеваний (ЦВЗ). Рассмотрены основные аспекты их патофизиологических взаимосвязей и значение для клинической практики. В настоящее время ЦВЗ, так же как и ХОБЛ, остаются доминирующей причиной смертности среди взрослого населения и связаны с большими экономическими потерями для государства. Частота выявления хронической ишемии головного мозга у больных ХОБЛ почти в 3 раза выше, чем в общей популяции. При ХОБЛ в 1,2 раза возрастает заболеваемость ишемическим инсультом, в 1,3 раза – геморрагическим инсультом и в 1,46 раза — субарахноидальными кровоизлияниями. Ключевое значение в развитии респираторной и цереброваскулярной коморбидности принадлежит хроническому системному воспалению, тканевой гипоксии, окислительному стрессу и другим типовым патологическим процессам, продукты которых (провоспалительные цитокины, активные формы кислорода, С-реактивный белок, некоторые нейротрофины и др. ) увеличивают проницаемость гематоэнцефалического барьера, оказывают повреждающее действие на клетки центральной нервной системы и ускоряют атерогенез в пре- и интрацеребральных артериях. С развитием эндотелиальной дисфункции нарушается ауторегуляция мозгового кровообращения. Системные проявления ХОБЛ тесно ассоциированы с различными вариантами структурно-функциональных изменений головного мозга: 46% белого вещества подвергается микроструктурной перестройке, уменьшается объем серого вещества, отмечается высокая распространенность церебральных микрокровоизлияний и нейродинамических нарушений. У больных ХОБЛ формируется венозная энцефалопатия, возникновению которой способствуют повышение внутригрудного давления и застой в системе верхней полой вены. Клинически это проявляется неврологической симптоматикой, выраженность которой зависит от степени тяжести ХОБЛ. Увеличивается частота когнитивных нарушений, а также тревоги, депрессии и панических расстройств. При ХОБЛ тяжелого течения диагностируются различные неврологические синдромы: астеновегетативный, пирамидный, вестибуло-мозжечковый, псевдобульбарный, амиостатический, неврастенический и др. Их выраженность зависит от тяжести гипоксии и гиперкапнии. Несмотря на большую значимость данной проблемы, многие патофизиологические и клинические аспекты коморбидности ХОБЛ и ЦВЗ остаются до конца не выясненными. Понимание их роли открывает перспективы для рациональной фармакотерапии.
Literature data of chronic obstructive pulmonary disease (COPD) and cerebrovascular diseases (CVD) comorbidity are represented in this review. Key aspects of this interaction and its importance for clinical medicine have been considered. CVD and COPD are the main mortality factors in adults, which contribute to great economic wastes. The incidence of chronic cerebral ischemia for COPD patients is almost three times as high as for general population. The incidence of ischemic stroke for COPD patients is 1,2 times higher than in general population. For hemorrhagic stroke and subarachnoid haemorrhages, this figures are 1,3 and 1,46 respectively. Chronic systemic inflammation, tissue hypoxia and oxidative stress play the crucial role in respiratory and cerebrovascular comorbidity. Metabolites of these processes (especially proinflammatory cytokines, reactive oxygen species, C-reactive protein and some neurotrophins) increase the permeability of blood-brain barrier, destroy brain cells and activate atherogenesis in pre- and intracerebral arteries. Endothelial dysfunction affects autoregulation of cerebral circulation. Systemic symptoms of COPD are closely associated with different structural-functional disorders of the brain such as reduction in white matter integrity, grey matter volume reduction and cerebral microbleeds. Also, venous encephalopathy is developed as a result of intrathoracic pressure elevation and stasis in superior vena cava system. These processes result in neurological symptomatology. The intensity of symptoms depends on COPD severity. The occurrence of cognitive impairment, psychic tension, depression, panic disorders also increases. However COPD and CVD comorbidity is an important problem of modern medicine, pathophysiologic mechanisms and clinic aspects of this problem remain unresolved. Understanding of their role opens perspectives for rational pharmacotherapy.
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1 ФГБОУ ВО «Тихоокеанский государственный медицинский университет» Минздрава России, Владивосток, Россия;
2 ФГАОУ ВО «Дальневосточный федеральный университет» Минобрнауки России, Владивосток, Россия