Recommendations of the European Society in Russian. Clinical recommendations for the specialization "cardiology". Signs and treatment of atherosclerosis of the vessels of the head and neck

One of the most important indicators of the functional state of the human body is the pressure in large arteries, that is, the force with which blood presses on their walls during the work of the heart. It is measured at almost any visit to the general practitioner, whether it is a program of preventive examinations or treatment of complaints of well-being.

A word about pressure

The blood pressure level is expressed as two numbers written as a fraction. The numbers mean the following: at the top - systolic pressure, which is popularly called the top, at the bottom - diastolic, or bottom. Systolic is fixed when the heart contracts and pushes blood out, diastolic - when it is maximally relaxed. The unit of measurement is a millimeter of mercury. The optimal pressure level for adults is 120/80 mm Hg. pillar. Blood pressure is considered elevated if it is more than 139/89 mm Hg. pillar.

A condition in which its level remains consistently high is called hypertension, and a steady decrease is called hypotension. The difference between the upper and lower should be 40-50 mmHg. Blood pressure changes during the day in all people, but in hypertensive patients these fluctuations are much sharper.

Why you need to know your blood pressure

Even a slight increase in blood pressure increases the risk of developing a heart attack, stroke, ischemia, heart and kidney failure. And the higher it is, the greater the risk. Very often, hypertension in the initial stage proceeds without symptoms, and the person does not even know about his condition.

Measurement of blood pressure is the first thing to do when complaining of frequent headaches, dizziness, weakness.

Hypertensive patients should measure blood pressure every day and monitor its level after taking the pills. People with high blood pressure should not be drastically reduced with medications.

Methods for measuring blood pressure

You can determine the level of blood pressure in a direct and indirect way.

Straight

This invasive method is highly accurate, but it is traumatic, since it consists in the direct insertion of a needle into a vessel or cavity of the heart. The needle is connected to the manometer by a tube containing an anticoagulant. The result is a blood pressure fluctuation curve recorded by a scribe. This method is most often used in cardiac surgery.

indirect methods

Usually, pressure is measured on the peripheral vessels of the upper extremities, namely on the elbow bend of the arm.

Nowadays, two non-invasive methods are widely used: auscultatory and oscillometric.

First (auscultatory), proposed by the Russian surgeon N. S. Korotkov at the beginning of the 20th century, is based on clamping the shoulder artery with a cuff and listening to the tones that appear when air is slowly released from the cuff. Upper and lower pressures are determined by the appearance and disappearance of sounds that are characteristic of turbulent blood flow. Measurement of blood pressure according to this technique is carried out using a very simple device, consisting of a pressure gauge, a phonendoscope and a cuff with a pear-shaped balloon.

When measuring blood pressure in this way, a cuff is placed on the shoulder area, into which air is pumped until the pressure in it exceeds systolic. The artery at this moment is completely clamped, the blood flow in it stops, the tones are not heard. When air is released from the cuff, the pressure decreases. When the external pressure is compared with the systolic pressure, blood begins to pass through the squeezed area, noises appear that accompany the turbulent flow of blood. They are called Korotkov's tones, and they can be heard with a phonendoscope. At the moment when they occur, the value on the pressure gauge is equal to the systolic blood pressure. When the external pressure is compared with the arterial pressure, the tones disappear, and at this moment the diastolic pressure is determined by the manometer.

To measure blood pressure according to Korotkov, a mechanical tonometer is used.

The microphone of the measuring device picks up the Korotkov tones and converts them into electrical signals that are fed to the recording device, on the display of which the values \u200b\u200bof the upper and lower blood pressure appear. There are other devices in which the emerging and disappearing characteristic noises are determined using ultrasound.

The method of measuring blood pressure according to Korotkov is officially considered the standard. It has both pros and cons. Among the advantages can be called high resistance to hand movement. There are a few more disadvantages:

Sensitive to noise in the room where the measurement is taken.
The accuracy of the result depends on whether the location of the phonendoscope head is correct and on the individual qualities of the person who measures blood pressure (hearing, vision, hands).
Skin contact with the cuff and microphone head is required.
It is technically complicated, which causes measurement errors.
It requires special preparation.

Oscillometric
With this method, blood pressure is measured with an electronic tonometer. The principle of this method is that the device registers pulsations in the cuff that appear when blood passes through the squeezed portion of the vessel. The main disadvantage of this method is that the hand must be motionless during the measurement. There are quite a few advantages:

For carrying out special training is not required.
The individual qualities of the measurer (vision, hands, hearing) do not matter.
Resistant to indoor noise.
Determines blood pressure with weak Korotkoff tones.
The cuff can be put on a thin jacket, while this does not affect the accuracy of the result.

Types of tonometers

Today, aneroid (or mechanical) and electronic devices are used to determine blood pressure.

The former are used to measure pressure using the Korotkoff method in a medical institution, since they are too complicated for home use, and untrained users receive measurement errors with results.

The electronic device can be automatic and semi-automatic. These blood pressure monitors are designed for daily home use.

Everyone can measure their own blood pressure and pulse with an electronic tonometer

General rules for measuring blood pressure

Pressure is most often measured in a sitting position, but sometimes it is done in a standing and lying position.

Daily blood pressure in people is constantly changing. It increases with emotional and physical stress. It can be measured not only in a calm state, but also during physical activity, as well as in between different types of loads.

Since the pressure depends on the condition of the person, it is important to provide the patient with a comfortable environment. The patient himself should not eat, do not engage in physical labor, do not smoke, do not drink alcoholic beverages, do not be exposed to cold for half an hour before the procedure.

During the procedure, you can not make sudden movements and talk.

It is recommended to take measurements more than once. If a series of measurements is taken, a break of about one minute (at least 15 seconds) and a change of position are needed between each approach. During the break, it is recommended to loosen the cuff.

The pressure on different hands can vary significantly, in connection with this, it is better to take measurements on the one where the level is usually higher.

There are patients whose pressure in the clinic is always higher than when measured at home. This is due to the excitement that many experience at the sight of medical workers in white coats. For some, this can happen at home, this is a reaction to the measurement. In such cases, it is recommended to take measurements three times and calculate the average value.

The procedure for determining blood pressure in different categories of patients

In the elderly

In this category of persons, unstable blood pressure is more often observed, which is associated with disturbances in the blood flow regulation system, a decrease in vascular elasticity, and atherosclerosis. Therefore, elderly patients need to take a series of measurements and calculate the average value.

In addition, they need to have their blood pressure measured while standing and sitting, because they often experience a sharp drop in pressure when changing positions, for example, when getting out of bed and assuming a sitting position.

In children

Children are recommended to measure blood pressure with a mechanical sphygmomanometer or an electronic semi-automatic device, while using a children's cuff. Before you measure your child's blood pressure yourself, you need to consult a pediatrician about the amount of air injected into the cuff and the time of measurement.

In pregnant women

By blood pressure, you can judge how well the pregnancy is proceeding. For expectant mothers, it is very important to constantly monitor blood pressure in order to start treatment on time and avoid serious complications in the fetus.

Blood pressure monitoring is essential during pregnancy

Pregnant women need to measure the pressure in a semi-recumbent state. If its level exceeds the norm or, conversely, is much lower, you should immediately contact your doctor.

With cardioarrhythmia

People who have a broken sequence, rhythm and heart rate need to measure blood pressure several times in a row, discard obviously incorrect results and calculate the average value. In this case, the air from the cuff must be released at a lower speed. The fact is that with cardioarrhythmia, its level can vary significantly from stroke to stroke.

Algorithm for measuring blood pressure

Measurement of blood pressure should take place in the following order:

The patient is seated comfortably on a chair so that his back is adjacent to the back, that is, he has support.
The hand is freed from clothing and laid on the table with the palm up, placing a towel roller or the patient's fist under the elbow.
A tonometer cuff is applied to the bare shoulder (two or three centimeters above the elbow, approximately at the level of the heart). Two fingers should pass between the arm and the cuff, its tubes pointing down.
The tonometer is at eye level, its arrow is at zero.
Find the pulse in the cubital fossa and apply a phonendoscope to this place with a slight pressure.
A valve is screwed on the pear of the tonometer.
The pear-shaped balloon is compressed and air is pumped into the cuff until the pulsation in the artery ceases to be heard. This occurs when the pressure in the cuff exceeds 20-30 mm Hg. pillar.
The valve is opened and air is released from the cuff at a rate of about 3 mm Hg. pillar, while listening to Korotkov's tones.
When the first constant tones appear, the pressure gauge readings are recorded - this is the upper pressure.
Continue to release air. As soon as the weakening Korotkoff tones disappear, the readings of the pressure gauge are recorded - this is the lower pressure.
Release air from the cuff, listening to tones, until the pressure in it becomes equal to 0.
The patient is allowed to rest for about two minutes and the blood pressure is measured again.
The cuff is then removed and the results recorded in a diary.

Correct position of the patient during blood pressure measurement

Wrist Blood Pressure Technique

To measure blood pressure at the wrist with an electronic device with a cuff, you must follow the following instructions:

Remove watches or bracelets from your arm, unbutton the sleeve and fold it back.
Position the cuff of the tonometer above the hand by 1 centimeter with the display facing up.
Place the arm with the cuff on the opposite shoulder, palm down.
With the other hand, press the "Start" button and put it under the elbow of the arm with the cuff.
Remain in this position until the air is automatically released from the cuff.

This method is not suitable for everyone. It is not recommended for people with diabetes mellitus, atherosclerosis and other circulatory disorders and changes in the vascular walls. Before using such a device, you need to measure the pressure with a tonometer with a cuff on the shoulder, then with a cuff on the wrist, compare the values \u200b\u200band make sure that the difference is small.

The wrist tonometer has both advantages and disadvantages.

Possible errors in measuring blood pressure

Mismatch between cuff size and arm circumference.
Wrong hand position.
Inflating the cuff too fast.

What to consider when measuring pressure

Stress can significantly change the readings, so you need to measure it in a calm state.
Blood pressure rises with constipation, immediately after eating, after smoking and drinking alcohol, with excitement, in a sleepy state.
It is best to carry out the procedure one to two hours after eating.
It is necessary to measure blood pressure immediately after urination, since it is elevated before urination.
The pressure changes after taking a shower or bath.
A nearby mobile phone can change the readings of the tonometer.
Tea and coffee can change blood pressure.
To stabilize it, you need to take five deep breaths.
It increases when you are in a cold room.

Conclusion

Determination of blood pressure at home follows the same principle as in a medical institution. The algorithm for measuring blood pressure remains approximately the same, but when using an electronic tonometer, the execution technique is noticeably simplified.

Blood pressure (BP) is the pressure that blood exerts on the walls of arteries. There are three indirect ways to measure blood pressure:

1) auscultatory

2) palpation

3) oscilloscope

The most common indirect method for determining blood pressure is the auscultatory method of N.S. Korotkov. Most often, this method determines blood pressure on the brachial artery. When measuring blood pressure, the following conditions must be observed:

1) The temperature in the room where the measurement is taken should be comfortable.

2) Within thirty minutes before measuring blood pressure, the subject should not strain, supercool, smoke, eat.

3) The shoulder of the subject should not be squeezed by clothing.

4) Within five minutes before measuring blood pressure, the subject should not change body position.

Rules for measuring blood pressure:

1) Blood pressure should be measured on both arms; if this is not possible, then the measurement of blood pressure is carried out on a non-dominant hand (for right-handers - on the left, for left-handers - on the right). In the presence of asymmetry of blood pressure, blood pressure is measured on the arm where higher blood pressure numbers were previously recorded.

2) The cuff must be applied so that its lower edge is 2-3 cm above the elbow.

3) The width of the cuff should be at least 120% of the diameter of the shoulder of the subject in its middle. The standard cuff width for adults is approximately 13 cm. Using this cuff to measure blood pressure in obese individuals will result in overestimated results. If such a cuff is used in children or in persons with a thin arm, then the blood pressure numbers will be underestimated. The rubber balloon, located inside the cuff, should cover at least 90% of the circumference of the upper arm in length (standard valley - 25.4 cm).

4) If blood pressure is measured while sitting, the subject's arm should be positioned so that the lower edge of the cuff is at the level of the fourth intercostal space (i.e. at the level of the heart), and the subject's shoulder should be at an angle of 45 ° to the body.

5) If blood pressure is measured lying down, the arm is placed on the bed at an angle of 45° to the body.

6) Air is quickly pumped into the cuff so that the pressure level exceeds 30 mm. rt. column pressure at which the pulsation in the cubital fossa disappeared, which is determined by palpation or auscultation. This rule allows, firstly, to avoid measurement errors in the presence of an auscultatory gap, and secondly, to reduce tissue pressure in the arm below the cuff, thereby increasing blood flow through the artery and, consequently, measurement accuracy.

7) The pressure in the cuff is reduced at a rate of 2 mm Hg. column / sec, without delay. If the subject has tachycardia, then the pressure in the cuff can be reduced somewhat faster, in the presence of bradycardia - somewhat more slowly.

8) Systolic blood pressure corresponds to the first appearance of tones audible by the ear.

9) Diastolic blood pressure is recorded at the moment of the disappearance of tones, which corresponds to the V Korotkoff phase. The exception is patients with aortic valve insufficiency, in whom phase IV corresponds to diastolic pressure. Phase IV is the moment of sudden and strong muting of tones, which is associated with the disappearance of the obstacle to blood flow through the vessel. Normally, IV and V phases are separated by no more than 10

mmHg pillar.

11) After fixing the level of blood pressure, it is necessary to quickly reduce the pressure in the cuff to zero.

12) Re-measurement of blood pressure on the same arm is possible no earlier than after 1 minute.

Systolic blood pressure is considered normal if it does not exceed 130 mm Hg. column, diastolic blood pressure - not exceeding 85 mm Hg. pillar.

The level of systolic blood pressure is from 130 to 139 mm Hg. column and diastolic blood pressure from 85 to 89 mm Hg. column is defined as "increased normal". Persons with "high normal" blood pressure should be examined at least once a year. For the diagnosis of arterial hypertension, it is considered sufficient that at least two measurements of blood pressure during at least two visits to the doctor, systolic blood pressure was at least 140 mm Hg. column and / or diastolic blood pressure - at least 90 mm Hg. pillar.

Systolic blood pressure is the maximum pressure in the arterial system developed during left ventricular systole. It is mainly due to the stroke volume of the heart and the elasticity of the aorta and large arteries.

Diastolic blood pressure is the minimum pressure in the arteries during diastole of the heart. It is largely determined by the value of the tone of peripheral arterioles.

Pulse blood pressure is the difference between systolic and diastolic blood pressure. Normally, it is 40-50 mm Hg. pillar. High pulse pressure can be detected with aortic valve insufficiency, with isolated systolic hypertension.

The average is that constant pressure that, without pulsation, can ensure the movement of blood through the vessels at the same speed as when moving with pulsation. Average blood pressure can be determined by the oscillographic method or calculated by the formula:

Mean pressure = Diastolic BP + 1/3 Pulse BP

Basal pressure is the pressure measured in the morning on an empty stomach at rest. Normally, it is the lowest.

If blood pressure is measured in patients with rigid sclerotic vessels, the resulting systolic blood pressure figures may exceed the true value by up to 30 mm Hg. pillar. In some patients, blood pressure can be difficult to measure because Korotkov's tones are hard to hear. This happens in patients with aortic stenosis, severe heart failure and reduced stroke volume, with narrowing of the lumen of the main artery. In order to improve the sound of the Korotkoff phases, it is recommended to do several flexions and extensions at the elbow before measuring blood pressure, as a result of which the vessels of the arm will expand.

The force of pressing the stethoscope to the hand does not affect the systolic BP figure, but the diastolic BP figures can be very low.

Measurement of blood pressure on the legs: The subject lies on his stomach. A cuff 20 cm wide is applied. The cuff is applied so that the pressure balloon is located on the back of the middle of the thigh. Auscultation is performed in the popliteal fossa. Normally, diastolic pressure in the arms and legs is the same, and systolic blood pressure in the legs is 20 mm Hg. pillar higher than on the hands.

STUDY OF THE DIGESTIVE ORGANS

INSPECTION

When examining the oral cavity, the following characteristics are checked and evaluated: 1) teeth (their number and condition, in the absence of teeth, the number of missing teeth and their serial numbers are noted, in the presence of unhealthy, carious teeth, their number and serial numbers are also noted); 2) gums (coloration of their mucosa, the presence of raids); 3) tongue (size, its color, the presence of plaque, the severity of the papillae, humidity); 4) palatine tonsils (their size, shape, color of the mucosa, the presence of raids); 5) coloring of the rest of the oral mucosa, the presence of a rash and raids on it.

When examining the abdomen, the following are checked and evaluated: 1) its size (enlarged, normal, retracted); 2) circumference (measured with a measuring tape at the level of the navel; 3) shape (correct, board-shaped, frog-like, etc.); 4) the symmetry of its halves; 5) participation in the act of breathing; 6) navel (retracted, protruding); 7) pattern of saphenous veins (yes, no); 8) visible peristalsis (yes, no); 9) the presence of hernial protrusions; 10) the presence of scars and striae.

They include a description of the diagnosis and treatment of major cardiovascular pathologies, as well as requirements for the organization of dynamic dispensary observation.

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From the article you will learn

arterial hypertension

Arterial hypertension is a persistent increase in systolic pressure above 140 mm Hg. and / or diastolic pressure above 90 mm Hg.

These thresholds are based on the results of clinical trials that have proven the benefit of therapy aimed at lowering blood pressure in patients with "hypertension" and "symptomatic arterial hypertension". The disease is chronic.

Heart failure (acute and chronic)

The 2020 National Clinical Guidelines for Cardiology consider HF as a condition associated with impaired function and structure of the heart muscle, in which the satisfaction of myocardial oxygen demand becomes possible only with an increase in the filling pressure of the heart.

Acute HF is life-threatening due to rapid onset of symptoms and development of pulmonary edema or cardiogenic shock.

Therefore, this condition requires the adoption of urgent measures and the speedy hospitalization of the patient in a cardiological hospital.

Chronic HF is characterized by a gradual increase in the intensity of symptoms up to the development of decompensation.

Cardiac ischemia

It can be organic (irreversible) and functional (transient). The most common cause of coronary artery disease is stenosing atherosclerosis as a result of spasm, "gluing" of platelets, intravascular thrombosis.

The concept of cardiac ischemia includes both stable and unstable conditions.

Diagnosis of atrial fibrillation
In 20-30% of patients with ischemic stroke, atrial fibrillation (AF) is diagnosed (before, after or during a stroke). In particular, much attention should be paid to asymptomatic (including self-limiting) episodes of AF.

Unscheduled screening for AF is indicated in patients over 65 years of age (by monitoring pulse or resting ECG) (class of evidence IB).
Systematic screening with ECG monitoring for AF is indicated in all patients older than 75 years or those at high risk of stroke (class IIaAT).
Resting ECG followed by ECG monitoring for at least 72 hours in post-stroke or TIA patients to detect AF (class IB).
Patients who have had a stroke are shown additional long-term ECG monitoring (including implantation of loop ECG recorders) to detect possible asymptomatic AF (class IIaAT).

In patients with implanted pacemakers or defibrillators, the presence of an atrial lead allows control of the atrial rhythm. Thus, patients with atrial high rate episodes (AHRE) can be identified. The presence of such episodes is associated with a significantly higher frequency of confirmed episodes of AF (5.56 times) and ischemic stroke or systemic embolism (2.56 times). At the same time, the incidence of stroke in patients with AHRE is lower than in patients with confirmed AF; AF is not detected in all such patients. Whether antithrombotic therapy is indicated in patients with AHRE is currently under investigation in two clinical trials (ARTESiA and NOAH - AFNET 6). Currently, it is recommended to monitor the atrial rate in patients with implanted pacemakers or defibrillators, and if episodes of high atrial rate are detected, they should be additionally examined to detect AF, as well as to assess the risk of ischemic complications.

In patients with implanted pacemakers or cardioverters, the atrial rate should be assessed regularly. If episodes of high atrial frequency are detected, an additional examination (ECG monitoring) is necessary to verify AF and prescribe appropriate treatment (class IAT).

Figure 1. Management of patients with episodes of high atrial rate recorded by implanted devices.

* - in some rare situations, anticoagulants can be prescribed without verification of AF. This approach requires detailed discussion with the patient and careful assessment of the risk/benefit ratio.

Bleeding risk assessment
This edition of the recommendations does not favor any particular scale for stratifying the risk of hemorrhagic complications. It is indicated that a number of such scales have been developed (mainly on patients taking vitamin K antagonists (VKA)): HAS-BLED, ORBIT, HEMORR2HAGES, ATRIA, ABC. Their use should help identify and, if possible, correct modifiable risk factors for bleeding (Table 1).

In patients with AF taking oral anticoagulants, special risk stratification scales should be used to identify potentially modifiable risk factors for bleeding (class IIaAT).

Table 1. Modifiable and non-modifiable risk factors for hemorrhagic complications in patients receiving anticoagulants (based on bleeding risk stratification scales)./p>

*-in different scales

Choice of antithrombotic drugs
The key points are the following:
Aspirin should not be used to prevent thromboembolic events in patients with AF
- Patients with a CHA2DS2-VASc score of 1 in men and 2 in women should consider anticoagulants (not aspirin)
- in patients with non-valvular AF, the first-line drugs are the "new" oral anticoagulants
Figure 2. Prevention of stroke risk in patients with AF.

Taking anticoagulants to prevent thromboembolic complications is indicated for patients with AF and index CHA2DS2-VASC2 or more for men, 3 or more for women (classIA).
For men with an index valueCHA2DS2-VASC1 and in women with an index valueCHA2DS2-VASC 2 it is possible to prescribe anticoagulants after assessing the individual characteristics of the patient and his preferences (class IIaB).
When anticoagulant therapy is first given to patients who can take NOACs (apixaban, dabigatran, rivaroxaban, edoxaban), they are preferred over VKAs (class IA).
In VKA users, the time spent by INR in the target range should be carefully monitored, and its maximum values should be strived for (class IA).
If the patient is already taking VKAs, switching to NOACs can be considered if INR stays in the target range is unsatisfactory despite good adherence to therapy, or based on the patient's own preferences (if there are no contraindications, for example, artificial heart valves) (class IIbBUT).

Occlusion or isolation of the left atrial appendage

Surgical isolation or occlusion of the left atrial appendage can be performed during an open heart procedure in a patient with AF (class IIbAT).
Surgical isolation or occlusion of the left atrial appendage may be performed during thoracoscopic intervention for AF (class IIbAT).

In the case of incomplete isolation of the LA appendage and the presence of residual blood flow, the risk of stroke may increase, therefore:

After surgical isolation or occlusion of the LA appendage, a patient with AF at high risk of stroke should continue anticoagulation (class IAT).

Left atrial appendage occlusion to prevent stroke may be performed in a patient with contraindications to long-term anticoagulant therapy (eg, a history of life-threatening bleeding with an unrecoverable cause) (class IIbB).

Stroke treatment
An effective and approved treatment for ischemic stroke is the administration of recombinant tissue plasminogen activator (rtPA) within 4.5 hours of symptom onset. Systemic thrombolysis is contraindicated in patients taking oral anticoagulants, but can be performed if INR is less than 1.7 in patients taking VKA, or in patients receiving dabigatran with APTT within normal limits and taking the last dose of the drug more than 48 hours ago. The feasibility of administering antidotes to NOACs followed by thrombolysis needs to be investigated in clinical trials. In patients with distal internal carotid or middle cerebral artery occlusion who are receiving anticoagulants, thrombectomy may be considered within 6 hours of symptom onset.
Secondary prevention of stroke
Initiation or resumption of anticoagulant therapy after ischemic stroke or TIA
The larger the stroke, the higher the risk of hemorrhagic complications in the case of early anticoagulant administration. Therefore, experts recommend starting anticoagulants between days 1 and 12, depending on the size of the stroke; in patients with large strokes, a second tomographic examination should be performed before starting anticoagulant therapy to rule out hemorrhagic transformation (Figure 3). A previous stroke or TIA is the most significant risk factor for recurrent stroke, so these patients benefit most from the use of anticoagulants. Both vitamin K antagonists and NOACs can be used. The use of NOACs is accompanied by slightly better outcomes, which is associated, first of all, with a lower number of intracranial hemorrhages. If the patient has had a TIA or stroke while on anticoagulant therapy, it is advisable to change the drug.
Figure 3 Initiation or resumption of anticoagulant therapy after ischemic stroke or TIA.

(these recommendations are mostly based on expert opinion and not on the results of prospective studies)
Initiation of anticoagulant therapy after intracranial hemorrhage
In some situations, anticoagulants may be prescribed 4-8 weeks after intracranial hemorrhage (especially if its cause has been eliminated or concomitant bleeding risk factors (Table 1), such as uncontrolled hypertension, have been corrected). Anticoagulant therapy in this situation reduces the risk of recurrent ischemic strokes and mortality. If a decision is made on anticoagulant therapy, it is preferable to choose the drug with the best safety profile. The decision to resume anticoagulants should be made collegially by a cardiologist/neurologist/neurosurgeon. Figure 4 shows the algorithm for prescribing anticoagulants after intracranial hemorrhage, based on expert opinion and data from retrospective studies.
Figure 4. Initiation or resumption of anticoagulant therapy after intracranial hemorrhage.

In patients with AF immediately after ischemic stroke, LMWH or UFH therapy is not recommended (class of recommendationsIII, level of evidenceA).
In those patients who have had a TIA or stroke while on anticoagulant therapy, adherence to therapy should be assessed and optimized (IIa C).
In anticoagulant-treated patients who have had a moderately severe or severe stroke, anticoagulant treatment should be interrupted for 3–12 days, depending on the results of a multidisciplinary team assessing the risk of bleeding and recurrent stroke ( IIaC).
Aspirin should be given before starting or resuming anticoagulant therapy for secondary prevention of stroke ( IIaB).
Systemic thrombolysis should not be performed in patients with an INR greater than 1.7 or in patients on dabigatran if the aPTT is above normal ( IIIC).
NOACs are preferred over VKAs or aspirin in patients with a previous stroke ( IB).
After a stroke or TIA, oral anticoagulant + antiplatelet combination therapy is not recommended (IIIB).
After intracranial hemorrhage in patients with AF, oral anticoagulants may be restarted after 4–8 weeks if the cause of the bleeding is corrected or risk factors are corrected ( IIbB).

How to minimize bleeding in people taking anticoagulants
The main way is the correction of modifiable risk factors (see Table 1). For example, normalization of SBP reduces the risk of bleeding.
Significant risk factors are also previous bleeding and anemia. The most common source of bleeding is the gastrointestinal tract. Compared with warfarin, dabigatran 150 mg twice daily, rivaroxaban 20 mg, and edoxaban 60 mg increase the risk of gastrointestinal bleeding. In those treated with dabigatran 110 mg twice daily and apixaban 5 mg twice daily, the risk of gastrointestinal bleeding was comparable to that of those receiving warfarin. The recently published results of observational studies have not reproduced these findings, indicating, apparently, a negligible negative effect of NOACs. In general, if the source of bleeding is identified and corrected, anticoagulants can be prescribed (this also applies to intracranial hemorrhage).
INR fluctuations are also a risk factor for bleeding. Therapy with warfarin should be changed to NOACs if TTR (time to stay in the target range of INR 2.0-3.0) is less than 70%. Dose of NOACs should also be adjusted, if necessary, based on patient age, renal function, and body weight.
Chronic alcoholism and binge drinking are disorders that should be corrected in patients receiving OAC (the risk of bleeding is increased due to liver damage, esophageal varices, high risk of injury, poor adherence to treatment).
Frequent falls and dementia are associated with a poor prognosis in patients with AF without clear evidence that this prognosis is associated with an increased risk of bleeding. Anticoagulants should not be given only to patients at very high risk of falling (eg, those with epilepsy and severe multisystem atrophy with supine falls) and some patients with severe dementia who are not cared for.
Genetic tests have little effect on the TTR and safety of warfarin therapy and are not recommended for routine use.
With regard to “bridge therapy” at the time of invasive interventions, it is currently believed that most cardiac procedures (PCI, pacemaker implantation) can be performed without discontinuation of anticoagulants, and if the intervention is associated with a high risk of bleeding and oral anticoagulants still need to be discontinued, bridge therapy should only be used in patients with mechanical prosthetic heart valves. The time of withdrawal of OAC should be minimal for the prevention of stroke.

Approaches to the treatment of patients with bleeding on the background of oral anticoagulants
Figure 5 Management of patients with acute bleeding on anticoagulant therapy.

FFP - fresh frozen plasma; CCP - prothrombin complex concentrate.

Standard coagulation tests provide no additional information in patients taking NOACs (with the exception of aPTT in those taking dabigatran). Specific tests are diluted thrombin time (HEMOCLOT) for dabigatran and calibrated anti-Xa quantitation for factor Xa inhibitors. However, these tests are often not available for routine use and most often have no value in the treatment of acute bleeding.
If the last dose of NOAC was taken recently (2-4 hours before bleeding), it may be appropriate to take activated charcoal and / or gastric lavage. Dialysis may be used to remove dabigatran from the bloodstream.
A specific antidote for dabigatran, idarucizumab, is currently available for clinical use.

Administration of oral anticoagulants to patients who have had bleeding or are at high risk of bleeding
Although anticoagulants should be interrupted at the time of active bleeding, they should be discontinued after it in rare situations. If the patient has had bleeding on the background of any anticoagulant, the drug should be changed. Most causes of major bleeding, such as uncontrolled hypertension, peptic ulcers, or intracranial microaneurysms, can be treated.
Recommendations on the management of patients with bleeding on the background of oral anticoagulants and the prevention of hemorrhagic complications:

Patients receiving anticoagulants should achieve control of arterial hypertension in order to reduce the risk of bleeding (class of recommendations IIA, level of evidence B).
For patients over 75 years of age, dabigatran should be given at a reduced dose of 110 mg twice daily to reduce the risk of bleeding ( IIbB).
In patients at high risk of gastrointestinal bleeding, dabigatran 150 mg twice daily, rivaroxaban 20 mg once daily, and enoxaban 60 mg daily should be preferred to VKAs or other NOACs ( IIAB).
Appropriate advice and treatment to prevent alcoholic excesses should be provided to patients who will be prescribed oral anticoagulants ( IIaB).
Genetic testing is not recommended before starting VKA treatment (IIIB).
Re-initiation of anticoagulants after a bleeding episode is possible in most patients after assessment by a multidisciplinary team, taking into account all options for anticoagulant treatment and other interventions for stroke prevention, and after improvement in the management of risk factors for bleeding and stroke ( IIaB).
In case of acute active bleeding, it is recommended to interrupt treatment with oral anticoagulants until the cause of bleeding is eliminated ( IC).

Combination therapy: oral anticoagulants and antiplatelet agents
Approximately 15% of patients with AF have ever experienced MI; 5-15% of patients with AF may require PCI. Co-administration of antithrombotic drugs significantly increases the risk of major bleeding. The addition of NOACs to mono- or dual antiplatelet therapy increases the risk of major bleeding by 79-134%, respectively, while only slightly reducing the risk of ischemic complications. Therefore, in general, one should strive to minimize the time of triple antithrombotic therapy as much as possible (Figures 6 and 7). NOACs should not be used in combination therapy at doses below those that have been shown to be effective in preventing stroke. As part of combination therapy, prasugrel and ticagrelor should be avoided in preference to clopidogrel (except in situations where drugs must be prescribed, for example, in the case of stent thrombosis while taking aspirin and clopidogrel).
Figure 6. Antithrombotic therapy after ACS in patients with AF requiring anticoagulants.

Figure 7. Antithrombotic therapy after elective PCI in patients with AF requiring anticoagulants.

In some categories of patients, dual therapy with OAC + clopidogrel may be prescribed instead of triple therapy ( IIbC).

Anticoagulants during and after catheter ablation for AF
Ablation can be performed without canceling VKA (INR 2-3). A sufficient amount of data has accumulated from highly qualified centers on the safe conduct of ablation against the background of NOACs. During ablation, it is necessary to inject UFH while maintaining an active clotting time of more than 300 seconds. After ablation, oral anticoagulants should be given for at least 8 weeks in all patients. In the future, anticoagulant therapy is prescribed depending on the risk of stroke (since the risk of recurrence of AF remains, including asymptomatic).

Anticoagulant therapy in pregnant women

Anticoagulant therapy is indicated for pregnant patients with AF and a high risk of stroke. To minimize the teratogenic effect and the risk of bleeding during childbirth, in the first trimester of pregnancy and 2-4 weeks before the expected date of delivery, heparin should be prescribed (at a dose adjusted for the patient's body weight). The rest of the time, both heparin and VKA can be used ( IB).
NOACs should not be given to pregnant women or women planning pregnancy (III).

In the third trimester, more frequent monitoring of the coagulogram is required, since pregnant women at this time often require larger doses of heparin or VKA to achieve adequate anticoagulation. If pregnant women with a mechanical prosthetic valve decide to stop taking warfarin at 6-12 weeks of gestation, they should definitely receive UFH or LMWH with adequate dose adjustment.

By materials :
P Kirchhof, S Benussi, D Kotecha, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. European Heart Journal
doi:10.1093/eurheartj/ehw210

The material was prepared by an employee of the Laboratory of Clinical Problems of Atherothrombosis of the Department of Angiology of the RKNPK named after V.I. A.L. Myasnikova Ph.D. Shakhmatova O.O.

The main cause of the most serious manifestation of coronary heart disease, myocardial infarction, is malnutrition of the muscle due to atherosclerotic vascular damage.

Atherosclerosis affects the wall of an artery. Due to the loss of elasticity, the possibility of sufficient expansion is lost. The deposition of atherosclerotic plaques from the inside causes a narrowing of the diameter of the vessel, making it difficult to deliver nutrients. A critical reduction is considered to be 50% of the diameter. At the same time, clinical symptoms of hypoxia (lack of oxygen) of the heart begin to appear. This is expressed in angina attacks.

Complete blockage of the coronary artery leads to the development of a site of necrosis (necrosis) in myocardial infarction. All over the world, this pathology is still considered one of the main causes of death in adults.

Timely stenting of the heart vessels can prevent the development of severe complications of atherosclerosis.

What is "stenting"?

The term "stenting" refers to an operation to install a stent inside an artery, which results in mechanical expansion of the narrowed part and restoration of normal blood flow to the organ. The operation refers to endovascular (intravascular) surgical interventions. It is carried out in the departments of the vascular profile. It requires not only highly qualified surgeons, but also technical equipment.

In surgery, techniques have been established not only for coronary stenting (heart vessels), but also for the installation of stents in the carotid artery to eliminate signs of cerebral ischemia, in the femoral artery for the treatment of atherosclerotic changes in the legs, in the abdominal aorta and iliac stents in the presence of pronounced signs of atherosclerotic lesions.

What is a "stent", varieties

A stent is a lightweight mesh tube strong enough to provide a scaffold for an artery for a long time. Stents are made of metal alloys (usually cobalt) in accordance with high technologies. There are many types. They differ in size, grid structure, the nature of the coating.

Two groups of stents can be distinguished:

uncoated - used in operations on medium-sized arteries;
covered with a special polymer shell that releases a medicinal substance during the year that prevents re-stenosis of the artery. The cost of such stents is much higher. They are recommended for installation in coronary vessels, require constant intake of drugs that reduce the formation of blood clots.

How is the operation going?

To stent the heart vessels, a catheter is inserted into the femoral artery, at the end of which there is a tiny balloon with a stent put on it. Under the control of the x-ray machine, the catheter is inserted into the mouth of the coronary arteries and moved to the required area of the narrowing. Then the balloon is inflated to the required diameter. In this case, atherosclerotic deposits are pressed into the wall. The stent, like a spring, expands and is left in place after the balloon is deflated and the catheter is removed. As a result, blood flow is restored.

The operation is usually performed under local anesthesia. Lasts from one to three hours. Before the operation, the patient is given drugs that thin the blood to prevent thrombosis. If necessary, install several stents.

After surgery, the patient spends up to seven days in the hospital under the supervision of a doctor. He is advised to drink plenty of fluids to remove contrast agents in the urine. Anticoagulants are given to prevent platelets from sticking together and forming blood clots.

Who is the operation, examination

The selection of patients with coronary heart disease for surgical treatment is carried out by a consultant cardiac surgeon. In the clinic at the place of residence, the patient undergoes the necessary minimum examination, including all mandatory blood and urine tests to determine the functioning of internal organs, a lipogram (total cholesterol and its fractions), blood clotting. Electrocardiography allows you to clarify the areas of myocardial damage after a heart attack, the prevalence and localization of the process. Ultrasound examination of the heart clearly in the pictures shows the functioning of all departments of the atria and ventricles.

In the inpatient department, angiography is mandatory. This procedure consists in the intravascular injection of a contrast agent and a series of x-rays taken as the vascular bed fills up. The most affected branches, their localization and the degree of narrowing are identified.

Intravascular ultrasound helps to assess the capabilities of the artery wall from the inside.

The examination allows the angiosurgeon to determine the exact location of the intended introduction of the stent, to identify possible contraindications for surgery.

Indications for operation:

severe frequent angina attacks, defined by a cardiologist as a pre-infarction condition;
support for a coronary artery bypass graft (bypass is the installation of artificial blood flow bypassing a blocked vessel), which tends to narrow over ten years;
according to vital indications in severe transmural infarction.

Contraindications

The inability to insert a stent is determined during the examination.

Widespread lesion of all coronary arteries, due to which there is no specific place for stenting.
The diameter of the narrowed artery is less than 3 mm.
Reduced blood clotting.
Violation of the function of the kidneys, liver, respiratory failure.
Allergic reaction of the patient to iodine preparations.

The advantage of stenting over other operations:

low invasiveness of the technique - there is no need to open the chest;
short period of stay of the patient in the hospital;
relatively low cost;
quick recovery, return to work, no long-term disability of the patient.

Operation complications

However, 1/10 of the operated patients had complications or undesirable consequences:

perforation of the vessel wall;
bleeding;
the formation of accumulation of blood in the form of a hematoma at the puncture site of the femoral artery;
stent thrombosis and the need for re-stenting;
impaired renal function.

Video showing the essence of the operation:

Recovery period

The postponed stenting of the heart vessels can greatly improve the patient's well-being, but this does not stop the atherosclerotic process, does not change the disturbed fat metabolism. Therefore, the patient will have to follow the doctor's prescription, monitor the level of cholesterol and blood sugar.

We will have to exclude animal fats from the diet and limit carbohydrates. It is not recommended to eat fatty pork, beef, lamb, butter, lard, mayonnaise and spicy spices, sausages, cheese, caviar, pasta from non-durum wheat, chocolate, sweets and pastries, white bread, coffee, strong tea, alcohol and beer, carbonated sweet drinks.

The diet requires that vegetables and fruits in salads or fresh juices, boiled poultry meat, fish, cereals, durum pasta, cottage cheese, sour-milk products, green tea be included in the diet.

It is necessary to establish 5 - 6 meals a day, monitor weight. If necessary, carry out unloading days.

Daily morning exercises increase metabolism, improve mood. You can not immediately take on heavy exercises. Walking is recommended, first for short distances, then with increasing distance. Slow walking up the stairs is popular. You can work out in the gym. Be sure to patients should learn to count their pulse. Avoid significant overload with increased heart rate. Of the sports, cycling and swimming are recommended.

Drug therapy is reduced to drugs that lower blood pressure (in hypertensive patients), statins to normalize cholesterol levels and drugs that reduce blood clots. Patients with diabetes mellitus should continue specific treatment as prescribed by the endocrinologist.

It is better if rehabilitation after stenting is carried out in a sanatorium-resort environment, under medical supervision.

The operation of stenting has been performed for about forty years. The methodology and technical support are constantly being improved. Indications are expanding, there are no age restrictions. It is recommended that all patients with coronary heart disease not be afraid to consult a surgeon, this is an opportunity to prolong an active life.

Signs and treatment of atherosclerosis of the vessels of the head and neck

Ensuring cerebral blood flow to a large extent depends on the condition of the arterial trunks, which are branches of the aorta. Atherosclerotic lesions of the cervical vessels is an essential factor in the pathogenesis of the development of chronic cerebral circulatory insufficiency. With atherosclerosis of the vessels of the neck and carotid arteries, a person has an increased risk of serious complications, up to death.

Atherosclerosis of the vessels of the neck is a systemic disease, the main cause of which is atherosclerotic plaques. With untimely diagnosis and treatment, such patients are at risk of ischemic stroke. Treatment of atherosclerosis of the blood vessels of the cervical region is carried out under the supervision of specialists in the field of vascular surgery and neurology.

State Characteristics

Atherosclerosis of the cervical vessels is a local manifestation of a systemic disorder of cholesterol metabolism. An increase in the concentration of cholesterol in the systemic circulation leads to the formation of atheromatous plaques, followed by stenosis of the carotid arteries. This type of blood vessel is a flexible tubular formation, elastic in its consistency and having smooth walls.

Age-related increase in blood pressure in the vessels of the neck, as well as an increase in the concentration of cholesterol in the blood, leads to the formation of the previously mentioned atherosclerotic plaques. The initial stage of the disease is characterized by the moment when fatty elements are deposited in the area of the vascular wall, to which connective tissue fibers and calcium particles are subsequently attached. The combination of these elements is called atherosclerotic plaque. This dense pathological formation is the main cause of the narrowing of the lumen of the blood vessel and circulatory disorders in this area.

With a narrowing of the lumen of the vessels of the neck by more than 50%, the patient has an increased risk of developing serious disorders associated with poor perfusion of brain tissues. Prolonged violation of perfusion leads to oxygen starvation and such a serious consequence as ischemic stroke of the brain. The study of atherosclerosis of the blood vessels of the neck, the symptoms and treatment is carried out by a specialist neurologist and cardiologist.

The reasons

Atherosclerotic lesions can cause blockage of various vessels in the body. The so-called vascular occlusion occurs against the background of a local accumulation of fatty elements, which are calcium salts, cholesterol, and fragments of destroyed blood elements. The following unfavorable factors contribute to the development of atherosclerotic lesions of the cervical vessels:

Prolonged increase in the concentration of glucose in the blood;
Irrational nutrition, which is characterized by excessive consumption of high-calorie foods, fatty, fried and spicy foods;
Alcohol and tobacco use;
Excess body weight;
Sedentary lifestyle (lack of exercise);
An increase in the synthetic function of the liver, as a result of which a large amount of endogenous cholesterol enters the systemic circulation;
Previously transferred infectious and inflammatory diseases.

People whose body is affected by several of the listed factors are at particular risk of developing atherosclerotic lesions of the vessels of the head and neck. With the formation of atheromatous plaques in the area of the main vessels and carotid arteries, a person automatically falls into the risk group for the occurrence of cerebrovascular disorders and cerebral accidents.

Symptoms

Like any kind of this disease, atherosclerosis of the arteries in the neck is characterized by a long period of absence of a clinical picture. In the case of progression of the disease, a person begins to be disturbed by minimal symptoms, which in most cases are perceived as a general malaise associated with fatigue. If a person has atherosclerosis of the vessels of the neck, the symptoms may be as follows:

Brief episodes of dizziness;
Intense pain in the head and neck, which are most often perceived as manifestations of vegetative-vascular dystonia and meteosensitivity;
Weakness and general malaise that occurs both at rest and during physical exertion;
Decreased visual acuity, as well as the appearance of so-called flies before the eyes;
Sleep disturbance, up to the formation of insomnia.

If the above symptoms occur, each person is recommended to contact a medical specialist for a comprehensive examination of the body. The faster the pathological process develops in the region of the vessels of the neck, the more intense the clinical picture of this disease manifests itself.

There is also a list of the most dangerous clinical manifestations indicating the development of persistent cerebrovascular disorders in the body. Such manifestations include:

Spontaneous loss of vision in one of the eyes, which is not associated with any traumatic injury to the head area;
Feeling of numbness and tingling in the upper or lower extremities. As a rule, such a symptom is accompanied by the inability to control the motor activity of the arms and legs;
Causeless loss of consciousness, which is accompanied by excessive sweating and pallor of the skin;
Violation of speech function, the impossibility of forming phrases and expressing thoughts;
Loss of orientation in the surrounding space.

In a person with similar symptoms, the risk of serious cerebrovascular disorders, up to a brain catastrophe, increases. Such a person needs emergency medical care, followed by hospitalization in the neurological department.

Diagnostics

In the initial stages of the diagnostic examination, the medical specialist collects and analyzes the patient's complaints. A standard medical survey in this case includes the collection of information regarding the presence of any chronic diseases of organs and systems, the intake of various groups of drugs, as well as the presence of a hereditary predisposition to the development of this disease. Diagnosis of atherosclerotic lesions of the blood vessels of the neck includes the following activities:

Ultrasound examination of the vessels of the neck with Doppler function. This non-invasive diagnostic technique allows you to evaluate the patency of the blood arteries in this area, as well as calculate the speed of blood flow. The level of stenosis of the lumen of the blood vessel is measured as a percentage. It can be said that the lower the percentage, the higher the risk of the formation of irreversible processes in the brain;
MRI angiography. Thanks to this technique, it is possible to assess in detail the condition of the vessels of the neck. Before the start of the study, each patient is injected with a special contrast agent, thanks to which the patency of the vessels is assessed on the resulting image;
Computed tomographic angiography. This non-invasive x-ray technique allows accurate visualization of the anatomical structures of the brain and blood vessels. Before the start of the study, the patient is injected with a special contrast agent, followed by an image. The resulting picture provides information about the degree of narrowing of the arteries and the exact localization of atheromatous plaques;
Angiographic study of the brain. This technique refers to minimally invasive methods for diagnosing this pathological condition. To obtain information about the state of the vessels of the neck, a special arterial catheter is installed for the patient, through which a contrast agent is supplied.

Treatment

Complex therapy of atherosclerotic lesions of the vessels of the cervical spine does not include such important points:

Diet therapy;
Lifestyle correction;
Medical therapy.

With the ineffectiveness of the above methods of correcting the condition, patients are prescribed surgical methods of treatment.

Diet and lifestyle modification

The organization of the correct diet for atherosclerosis of the vessels of the neck is of great importance. The key goal of diet therapy is to limit the intake of foods that can cause an increase in the concentration of cholesterol in the systemic circulation. The initial stage of atherosclerosis of the vessels of the neck, provides for such dietary recommendations:

In the daily diet, it is recommended to give preference to fresh fruits, vegetables and fruit juices;
From the daily diet, it is necessary to exclude foods rich in animal fats, smoked meats, fried foods and fast food;
Sea fish and seafood are of particular benefit to the body of people suffering from atherosclerosis of the vessels of the neck. These food products contain biologically active substances that help reduce blood cholesterol levels and normalize metabolic processes in the body.

If atherosclerosis of the arteries of the neck is detected, a person is recommended to stop drinking alcohol and smoking as soon as possible. In the presence of excess body weight, a person is recommended not only to correct the diet, but also to increase physical activity. With an increase in blood pressure, the patient is prescribed antihypertensive therapy. For some patients who have atherosclerosis of the main arteries of the neck, to eliminate the psycho-emotional factor, the formation of atherosclerosis, consultations of a psychotherapist are prescribed.

Medical therapy

The main goal of drug treatment of atherosclerosis of the vessels of the neck is the prevention of cerebral catastrophe. The plan and duration of treatment is compiled by a medical specialist on an individual basis. The choice of treatment tactics is influenced by the degree of narrowing of the lumen of the blood vessels, as well as the risk of the formation of persistent ischemia of the brain tissue.

Effective drug therapy is possible only if the degree of narrowing of the lumen of the blood vessels does not exceed 50%. In addition, drug treatment is carried out if the patient disagrees with the surgical intervention. In matters of treatment of atherosclerotic lesions of the vessels of the neck, the following groups of pharmaceuticals are used:

Antihypertensive agents. This large group of drugs includes ACE inhibitors, diuretics, calcium channel blockers, and beta-blockers. Under the influence of this group of drugs, the regulation and control of blood pressure indicators is carried out. The use of these funds is due to the fact that an increase in blood pressure is one of the main causes of the formation of atherosclerosis;
Disaggregants. And this group of drugs includes Clopidogrel, Aspirin, Ticlopidin. The action of these medicines is aimed at preventing blood clotting and thinning it. This is especially true for people suffering from atherosclerotic lesions of the vessels of the neck, since it is difficult for thick blood to pass through the narrowed arterial lumen;
Statins. This group of drugs provides a decrease in the concentration of cholesterol in the systemic circulation, which is the prevention of the deposition of atheromatous plaques.

Surgery

Surgical methods of treatment are recommended for patients with a high and moderate degree of stenosis of the neck vessels. The main goal of surgery is to prevent such a formidable complication as a stroke. During surgery, atheromatous plaques are removed and the lumen of the sclerotic vessel is expanded.

In order to treat atherosclerosis of the cervical vessels, the following operations are used:

carotid stenting. Thanks to this technique, it is possible to expand the lumen of the blood vessel. This intervention is performed under angiographic control. The initial stage of the operation is to bring a flexible catheter to the site of atheromatous plaque localization. For this purpose, the patient is placed an arterial femoral catheter. Through the installed catheter, another catheter is inserted into the lumen of the vessel, which contains a special balloon. Under the action of this balloon, the vascular lumen expands and the atheromatous plaque flattens;
Carotid endarterectomy. During this surgical intervention, atheromatous plaques are eliminated. During the operation, the medical specialist makes a skin incision in the area of the projection of the carotid artery, after which he places a clamp on it below the stenotic zone. The next stage of the operation is the dissection of the artery, its purification from fatty deposits, followed by suturing;
Installation of shunts on the carotid artery. The essence of this procedure is the creation of alternative vascular pathways through which blood will flow to the brain. The saphenous vein of the lower extremity is used as a biological material to create an anastomosis. After creating the so-called bypass, a person's blood flow to the brain tissues is normalized, which reduces the risk of ischemia and cerebral catastrophe.

Prevention

It is much easier to prevent possible complications of the disease than to treat them. Prevention of this pathological condition directly depends on the cause of its occurrence. The general plan of preventive measures can be divided into the following points:

Refusal to drink alcohol and tobacco;
Rationalization of nutrition and restriction of foods rich in animal fats;
Increased motor activity and prevention of hypodynamia;
Monitoring blood glucose levels;
With a tendency to develop arterial hypertension, it is recommended to be observed by a cardiologist and therapist, as well as take appropriate medications.

It is possible to cure signs of atherosclerosis with folk remedies only in combination with conservative methods.

Aneurysm of the thoracic aorta (aorta of the heart): causes, symptoms, diagnosis, treatment, prognosis

The aorta is one of the large main vessels, which departs directly from the heart and promotes the movement of blood into the arteries of a smaller diameter. Arterial blood, enriched with oxygen, moves in it, which reaches all human organs through the outgoing arteries. The aorta starts from the left ventricle of the heart in the form of a bulb with a diameter of about 2.5-3 cm, then continues in the form of the ascending section, the aortic arch and the descending section. The descending aorta is divided into thoracic and abdominal sections.

An aneurysm is a localized weak spot in the vascular wall that bulges outward under pressure from the blood in the vessel. This protrusion can reach different sizes, up to a giant aneurysm (more than 10 cm in diameter). The danger of such aneurysms is that due to the instability of the vascular wall in this place, blood can flow between the inner membranes of the artery with their delamination. Sometimes an aneurysm can rupture with massive internal bleeding, leading to instant death of the patient. An aneurysmal sac can occur anywhere in the aorta, but, according to statistics, it is less common in the thoracic region than in the abdominal region (25% and 75%, respectively). The shape of the protrusion can take spindle-shaped and saccular forms.

Causes of thoracic aortic aneurysm

The causative factors of thoracic aortic aneurysm often cannot be determined in an individual patient. In general, we can say that men over fifty are most predisposed to the development of an aneurysm of the ascending aorta, that is, gender and age affect the weakness of the vascular wall in the arteries, including in the aorta.

In addition, in most cases, there is a relationship between the aneurysm and the existing aortic atherosclerosis. Due to the fact that atherosclerosis is the cause of other cardiac diseases, in patients with past heart attacks, strokes and coronary heart disease, thoracic aortic aneurysm is recorded more often than in individuals without such diseases.

Some patients have congenital structural features of the cardiovascular system. They are especially pronounced in people with Marfan syndrome. This is a syndrome characterized by "weakness" of the connective tissue. Since there are varieties of connective tissue in every organ, the walls of the vessel also consist of a connective tissue frame. In Marfan syndrome, violations of the synthesis of structural proteins lead to the fact that the vascular wall gradually becomes thinner and becomes susceptible to the formation of an aneurysm.

Sometimes an aneurysm can develop within a few years of a chest injury. The time of occurrence of an aneurysm is different for everyone and ranges from a year or two to 15-20 or more.

Of the rarer causative diseases, tuberculosis and syphilis with damage to the ascending part, the aortic arch or its descending section, as well as other infectious diseases with inflammation of the aortic wall - with aortitis, can be noted.

In addition to the predisposing factors that can cause thinning of the aortic wall, an influence from the inside must lead to the formation of a protrusion, and this is due to high blood pressure. Therefore, patients with arterial hypertension are at risk for the development of thoracic aortic aneurysm.

Symptoms of a thoracic aortic aneurysm

With an aneurysm of small size (less than 2-3 cm in diameter), symptoms may be absent for quite a long time and appear only when complications have already arisen. This is bad for the patient, because for a long time a person lives without unpleasant symptoms, without suspecting anything, and then he may have a dissection or rupture of the aneurysm, which has an unfavorable outcome.

In the case when an aneurysm of the ascending aorta or arch of the aorta puts pressure on the mediastinal organs in the chest, the patient has the corresponding symptoms. Usually, when an aneurysm reaches an aortic arch of considerable size, signs such as:

Attacks of dry cough with compression of the trachea,
Feeling of suffocation during exertion or at rest,
Difficulty swallowing food due to pressure on the esophagus
Hoarseness of voice, up to complete aphonia, with compression of the recurrent nerve that innervates the larynx and vocal cords,
Pain in the region of the heart, radiating to the intercostal region,
With compression of the superior vena cava, the patient notes swelling of the skin of the face and neck, swelling of the cervical veins, sometimes on the one hand, bluish coloration of the skin of the face,
With compression of the nerve bundles, unilateral constriction of the pupil and drooping of the upper eyelid can be observed, combined with dry eyes and united by the concept of Horner's syndrome.

The clinical picture of a complicated aneurysm of the thoracic aorta proceeds rapidly and differs in the severity of the patient's condition.

Diagnosis of uncomplicated thoracic aortic aneurysm

The diagnosis of the disease can be established at the stage of questioning and examining the patient. In addition to anamnestic data, the doctor evaluates the presence of objective signs - a feeling of pulsation when probing the jugular fossa above the sternum with aneurysm of the aortic arch, a pulsating formation visible to the eye under the xiphoid process of the sternum, increased heart rate, pallor and cyanosis of the skin.

To confirm the diagnosis, the patient is shown additional research methods:

Treatment of uncomplicated aortic aneurysm

Unfortunately, aortic aneurysm is a completely irreversible anatomical formation, therefore, without surgical treatment, progression of its growth with an increasing risk of complications is possible. Most often, thoracic aortic aneurysms, reaching a diameter of 5-6 cm or more, are susceptible to this. In this regard, aneurysms of precisely this size are subject to surgical treatment, and aneurysms less than 5 cm can be subjected to expectant management and conservative treatment of the underlying disease, if possible.

So, for example, individuals with small thoracic aortic aneurysms, without signs of compression of nearby organs and with a minimal risk of dissection, require only dynamic observation with a cardiologist examination every six months, with echocardioscopy and MSCT of the heart every six months or a year. In the presence of atherosclerosis and hypertension, the patient is shown a constant intake of drugs (lipid-lowering drugs - statins, antihypertensives, diuretics, etc.).

With an increase in the growth of the aneurysm, upon receipt of data on MSCT or echo-CS, indicating in favor of dissection of the aortic wall, the patient is indicated for surgery. So, with an increase in the diameter of the aneurysm by more than half a centimeter in six months or a centimeter per year, it is an absolute indication for surgery. But usually the dynamics of aneurysm growth is about one millimeter per year for the ascending and descending aorta.

The surgical method of treatment includes two types of surgery. The first technique is to perform open-heart surgery using a heart-lung machine and is performed by dissecting the chest wall - thoracotomy. The operation is called aortic aneurysm resection. After access to the thoracic aorta, the aneurysmal sac is excised, and an artificial graft is applied to the severed walls of the aorta with sutures. After painstaking, careful imposition of anastomoses between the ascending aorta, the arch and the thoracic part of the descending aorta, layer-by-layer suturing of the wound is carried out.

Currently, grafts made from a material called dacron are used for aortic arthroplasty. The prosthesis can be installed in any part of the thoracic aorta - in the ascending, in the arch or in the descending. For better engraftment of the transplant, it is covered with collagen and antibacterial drugs. This avoids inflammation and parietal thrombus formation in the lumen of the prosthetic aorta.

The second technique for eliminating an aneurysm is that a probe with an endoprosthesis at the end is brought to the patient through the arteries to the site of the aneurysm, which is fixed above and below the aneurysmal sac. Thus, the aneurysm is "turned off" from the bloodstream, which prevents the development of complications.

Due to the fact that at present endovascular techniques are only beginning to gain mass use, aneurysm resection by open access using a heart-lung machine is most often used. Of course, the risk from the use of this device is more serious than from endovascular intervention, so a cardiac surgeon may suggest the combined use of these two techniques in one patient.

Which of the methods to apply in a particular patient, and when, is decided by the doctor during dynamic monitoring of the patient. Therefore, patients with newly diagnosed complaints, as well as those with an already established diagnosis of thoracic aortic aneurysm, should contact a cardiologist and a cardiac surgeon in a timely manner, and subsequently visit them every six months in compliance with all medical recommendations.

Are there any contraindications for the operation?

Due to the fact that aneurysm of the thoracic aorta is an extremely dangerous disease, there are no absolute contraindications for an operation, especially if it is carried out for health reasons. Relative contraindications include acute infectious, acute cardiological and neurological diseases, as well as exacerbation of severe chronic pathology. But in the event that a planned intervention on the aorta is planned, and there is no risk to life due to the delay of the operation, it can be postponed to a more favorable period, after the patient's condition has stabilized. A special risk group includes elderly patients (over 70 years old), especially those with severe chronic heart failure. In this case, the question of the expediency of the operation is decided strictly individually.

Video: example of thoracic aortic arthroplasty

Complications without treatment

Despite the fact that the operation for resection of an aneurysm of the thoracic aorta is many hours and difficult, you should not be afraid of it if the doctor confidently recommends surgery. According to statistics, mortality on the operating table and in the early postoperative period ranges from 5 to 15%, according to different authors. This is incomparably less than the mortality without treatment, because in the first five years after the onset of complaints caused by a growing aneurysm, or from the moment an aneurysm is diagnosed, up to 60-70% of patients die. In this regard, the operation is actually the only way to prevent complications from the thoracic aortic aneurysm. Without treatment, the patient will inevitably develop a dissection and rupture of the aneurysm, but when this happens, no doctor can predict. In this regard, an aortic aneurysm resembles a time bomb.

So, complications of this disease are dissecting aneurysm, aneurysm rupture and thromboembolic conditions. All of them are manifested by a general severe condition, with severe pain in the chest and abdomen (when the dissection spreads to the descending aorta). Paleness of the skin, cold sweat, faintness, and a picture of shock are also noted. Without treatment, and often even with emergency surgery, the patient dies.

Are there complications after the operation?

Complications after surgery occur infrequently (about 2.7%), but there is still a certain risk of their development. So, the most dangerous are bleeding from the aorta, acute heart attack, acute stroke and paralysis of the lower extremities (in the treatment of thoracoabdominal aneurysms - on the border of the thoracic and abdominal sections). Complications can be caused not only by the failure of the sutures on the aortic wall, but also by the ingress of blood clots into smaller arteries extending from the bulb and from the arch that supply the heart and brain. The occurrence of complications depends not so much on the quality of the operation, but rather on the initial state of the aneurysm and the presence of thrombotic masses in it.

Where is an aortic resection performed and what is its cost?

Resection surgery with thoracic aortic replacement can be performed in many large federal centers. The operation can be performed both on a quota and at the expense of the patient's personal funds. The cost of intervention can vary greatly depending on the location of the aneurysm, the type of prosthesis and the type of operation (open or intravascular). So, for example, in Moscow, resection of an aneurysm is performed in the hospital. Sechenov, at the Institute of Surgery. Vishnevsky, in the hospital. Botkin and in other clinics. The price ranges from 50,000 rubles to 150,000 rubles and more.

Forecast

The prognosis for an aneurysm of the thoracic aorta depends on the location, size of the aneurysmal sac, and the dynamics of the growth of the aneurysm. In addition, the prognosis is determined by the degree of risk of delamination and rupture. For example, one of the criteria for assessing the degree of risk is the calculation of the aortic diameter index. This indicator is defined as the ratio of the diameter of the aneurysm in cm to the area of the patient's body in m. An indicator of less than 2.75 cm / m "indicates that the prognosis for the patient is likely to be favorable, since the risk of rupture is less than 4% per year, an indicator of 2.75-4.25 indicates a moderate risk (8%), and a relatively favorable prognosis , and an index of more than 4.25 should alert the doctor, since the risk of rupture is high (more than 25%), and the prognosis remains doubtful. That is why the patient should follow the recommendations of the cardiac surgeon and agree to the operation if the doctor insists, since surgery significantly reduces the risk of developing fatal complications of thoracic aortic aneurysm.

Video: aortic aneurysm in the program "Live healthy"

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