Modern treatment of ischemic heart disease. What drugs are prescribed for coronary heart disease? Potassium channel activator nicorandil

IHD treatment consists of tactical and strategic measures. The tactical task includes the provision of emergency care to the patient and the relief of an angina attack (about MI we will talk in a separate chapter), and strategic interventions are, in essence, the treatment of coronary artery disease. Let's not forget about the strategy of managing patients with ACS.

I. Treatment of angina pectoris. Since in the vast majority of cases the patient goes to the doctor due to pain (the presence of angina pectoris), the elimination of the latter should be the main tactical task.

The drugs of choice are nitrates ( nitroglycerin, isosorbide dinitrate ). Nitroglycerine (angibid, angided, nitrangin, nitroglin, nitrostat, trinitrol etc.), tablets for sublingual administration of 0.0005 each, the stopping effect occurs after 1-1.5 minutes and lasts 23-30 minutes. It is desirable to take in a sitting position, i.e. with legs down. If there is no effect from one tablet after 5 minutes, you can take the second, then the third, but not more than 3 tablets within 15 minutes. In severe cases nitroglycerine enter in / in. You can use buccal forms - plates trinitrolonga that are applied to the mucous membrane upper gum over canines and small molars. Trinitrolong able to quickly stop an attack of angina pectoris, and to prevent it. If a trinitrolong taken before going out, walking, commuting or before other physical activity, it can provide prevention of angina attacks. In case of poor tolerance of nitropreparations, they are replaced with molsidomine (corvaton ).

If the pain cannot be stopped, then this is most likely not an ordinary angina attack. We will analyze the provision of assistance for intractable angina pectoris below (see "Strategy for the management of patients with ACS").

Treatment regimens for patients with angina pectoris

Standard of emergency care for angina pectoris.

1. With an anginal attack:

It is convenient to seat the patient with his legs down;

- nitroglycerine - tablets or aerosol of 0.4-0.5 mg under the tongue three times in 3 minutes (with intolerance nitroglycerin - Valsalva maneuver or carotid sinus massage);

Physical and emotional peace;

BP correction and heart rate.

2. With a persistent attack of angina pectoris:

oxygen therapy;

with angina pectoris - anaprilin 10-40 mg under the tongue, with variant angina - nifedipine 10 mg under the tongue or in drops by mouth;

heparin 10,000 IU IV;

give to chew 0.25 g acetylsalicylic acid .

3. Depending on the severity of pain, age, condition (without delaying the attack!):

- fentanyl (0.05-0.1 mg) or promedol (10-20 mg), or butorphanol (1-2 mg), or analgin (2.5 g) with 2.5-5 mg droperidol intravenously slowly or fractionally.

4. When ventricular extrasystoles 3rd-5th gradation:

- lidocaine in / in slowly 1 - 1.5 mg / kg and every 5 minutes at 0.5-0.75 mg / kg until an effect is obtained or a total dose of 3 mg / kg is reached. To prolong the effect obtained - lidocaine up to 5 mg/kg IM.

Patients with unstable angina or suspected myocardial infarction are treated as patients with ACS. The approach to managing these patients is outlined below.

Management strategy for patients with ACS .

The course and prognosis of the disease largely depend on several factors: the extent of the lesion, the presence of aggravating factors such as diabetes mellitus, arterial hypertension, heart failure, advanced age, and to a large extent on the speed and completeness of medical care. Therefore, if ACS is suspected, treatment should begin at the prehospital stage. The term "acute coronary syndrome" (ACS) was introduced into clinical practice when it became clear that the question of the use of certain active methods treatment, in particular thrombolytic therapy, should be decided before establishing the final diagnosis - the presence or absence of large-focal myocardial infarction.

At the first contact of the doctor with the patient, if there is a suspicion of ACS, according to clinical and ECG signs, it can be attributed to one of its two main forms.

Acute coronary syndrome with ST segment elevations. These are patients with pain or other unpleasant sensations (discomfort) in chest and persistent ST segment elevations or "new" (new or presumably new) left bundle branch block on the ECG. Persistent ST-segment elevations reflect the presence of acute complete occlusion of the coronary artery. The goal of treatment in this situation is the rapid and stable restoration of the lumen of the vessel. For this, thrombolytic agents are used (in the absence of contraindications) or direct angioplasty (if there are technical possibilities).

Acute non-ST elevation coronary syndrome. Patients with chest pain and ECG changes indicative of acute myocardial ischemia, but without ST segment elevations. These patients may have persistent or transient ST depressions, inversion, flattening, or pseudonormalization of the T wave. The ECG on admission is also normal. The management strategy of such patients is to eliminate ischemia and symptoms, follow-up with repeated (serial) registration of electrocardiograms and determination of markers of myocardial necrosis (cardiac troponins and/or creatine phosphokinase MB-CPK). In the treatment of such patients, thrombolytic agents are not effective and are not used. Treatment tactics depend on the degree of risk (severity of the condition) of the patient.

In each case, deviations from the recommendations are permissible depending on the individual characteristics of the patient. The doctor makes a decision taking into account the anamnesis, clinical manifestations, data obtained during the observation of the patient and examination during hospitalization, as well as based on the capabilities of the medical institution. AT in general terms the strategy for managing a patient with ACS is shown in Fig.

LMWHs are low molecular weight heparins. PCI - percutaneous coronary intervention. UFH, unfractionated heparin.

The initial assessment of a patient presenting with chest pain or other symptoms suggestive of myocardial ischemia includes a thorough history, physical examination, with special attention to the possible presence of valvular heart disease (aortic stenosis), hypertrophic cardiomyopathy, heart failure, and lung diseases.

An ECG should be recorded and ECG monitoring should be started to control the heart rhythm (multichannel ECG monitoring is recommended to control myocardial ischemia).

Patients with persistent ST elevation on the ECG or "new" left atrioventricular bundle branch block are candidates for immediate treatment to restore blood flow to the occluded artery (thrombolytic, PCV).

Drug treatment of patients with suspected ACS (with the presence of ST-segment depression / T-wave inversion, false-positive T-wave dynamics or normal ECG with an obvious clinical picture of ACS) should be started with oral administration aspirin 250-500 mg (first dose - chew uncoated tablet); then 75-325 mg, 1 time / day; heparin (UFH or LMWH); beta blockers. With ongoing or recurring chest pain, nitrates are added orally or intravenously.

The introduction of UFH is carried out under the control of APTT (activated partial thromboplastin time) (it is not recommended to use the determination of blood clotting time to control heparin therapy) so that after 6 hours after the start of administration it is 1.5-2.5 times higher than the control (normal) indicator for the laboratory of a particular medical institution and then steadfastly kept at this therapeutic level. Initial dose UFG : bolus 60-80 U/kg (but not more than 5,000 U), then infusion 12-18 U/kg/h (but not more than 1250 U/kg/h) and determination of APTT 6 hours later, after which the rate is corrected drug infusion.

APTT determinations should be performed 6 hours after any dose change. heparin . Depending on the result obtained, the infusion rate (dose) should be adjusted in order to maintain the APTT at the therapeutic level. If the APTT is within the therapeutic limits with 2 consecutive measurements, then it can be determined every 24 hours. In addition, the determination of the APTT (and the correction of the dose of UFH depending on its result) should be carried out with a significant change (deterioration) in the patient's condition - the occurrence of repeated attacks myocardial ischemia, bleeding, arterial hypotension.

Myocardial revascularization. In case of atherosclerotic damage to the coronary arteries, which allows for a revascularization procedure, the type of intervention is chosen based on the characteristics and extent of stenoses. In general, the recommendations for choosing a method of revascularization for NST are similar to the general recommendations for this method of treatment. If selected balloon angioplasty with or without stent placement, it can be performed immediately after angiography, within the same procedure. In patients with single-vessel disease, PCI is the main intervention. CABG is recommended for patients with lesions of the left main coronary artery and three-vessel disease, especially in the presence of LV dysfunction, except in cases with serious concomitant diseases that are contraindications to surgery. In two-vessel and in some cases three-vessel lesions, both CABG and PTCA are acceptable.

If it is impossible to perform revascularization of patients, it is recommended to treat heparin (low molecular weight heparins - LMWH) until the second week of the disease (in combination with maximum anti-ischemic therapy, aspirin and, if possible, clopidogrel ). After stabilization of the condition of patients, consideration should be given to invasive treatment in another medical institution that has the appropriate capabilities.

II. Treatment of chronic coronary disease. So - the acute period behind. Strategic treatment of chronic coronary insufficiency. It should be comprehensive and aimed at restoring or improving coronary circulation, curbing the progression of atherosclerosis, eliminating arrhythmias and heart failure. The most important component of the strategy is to address the issue of myocardial revascularization.

Let's start with catering. The nutrition of such patients should be low-energy. The amount of fat is limited to 60-75 g / day, and 1/3 of them should be of plant origin. Carbohydrates - 300-400 g. Exclude fatty varieties meat, fish, refractory fats, lard, combined fats.

The use of medicines aimed at stopping or preventing an attack of angina pectoris, maintaining adequate coronary circulation, affecting the metabolism in the myocardium to increase its contractility. For this, nitro compounds, beta-adrenergic receptor blockers, CCBs, antiadrenergic drugs, potassium channel activators, antiplatelet agents are used.

Anti-ischemic drugs reduce myocardial oxygen consumption (reducing heart rate, blood pressure, suppressing left ventricular contractility) or cause vasodilation. Information on the mechanism of action of the drugs discussed below is given in the appendix.

Nitrates have a relaxing effect on the smooth muscles of blood vessels, cause the expansion of large coronary arteries. According to the duration of action, nitrates are distinguished short action (nitroglycerine for sublingual use, spray), medium duration of action (tablets Sustaca, Nitronga, Trinitrolonga ) and long-term action ( isosorbitol dinitrate -20 mg; patches containing nitroglycerine , erinite 10-20 mg each). The dose of nitrates should be gradually increased (titrated) until symptoms disappear or side effects (headache or hypotension) occur. Prolonged use of nitrates can lead to addiction. As symptoms are controlled, intravenous nitrates should be replaced with non-parenteral forms, while maintaining some nitrate-free interval.

Beta-adrenergic blockers. The goal of taking β-blockers orally should be to achieve a heart rate of up to 50-60 in 1 min. β-blockers should not be prescribed to patients with severe atrioventricular conduction disorders (1st degree RV block with PQ > 0.24 s, II or III degree) without a working artificial pacemaker, a history of asthma, severe acute LV dysfunction with signs of heart failure. The following drugs are widely used - anaprilin, obzidan, inderal 10-40 mg, daily dose up to 240 mg; trasicore 30 mg, daily dose - up to 240 mg; cordanum (talinolol ) 50 mg, per day up to 150 mg.

Contraindications for the use of β-blockers: severe heart failure, sinus bradycardia, peptic ulcer, spontaneous angina.

Calcium channel blockers subdivided into direct-acting drugs that bind calcium on membranes ( verapamil, finoptin, diltiazem ), and indirect action, having the ability of membrane and intracellular effects on calcium current ( nifedipine, corinfar, felodipine, amlodipine ). Verapamil, Isoptin, Finoptin available in tablets of 40 mg, daily dose - 120-480 mg; nifedipine, corinfar, feninidine 10 mg, daily dose - 30-80 mg; amlodipine - 5 mg, per day - 10 mg. Verapamil can be combined with diuretics and nitrates, and drugs of the group corinfar - also with β-blockers.

Mixed action antiadrenergic drugs - amiodarone (cordarone ) - have antiangial and antiarrhythmic effects.

Potassium channel activators (nicorandil ) cause hyperpolarization of the cell membrane, give a nitrate-like effect by increasing the content of cGMP inside the cell. As a result, the relaxation of the SMC occurs and the “cellular protection of the myocardium” increases during ischemia, as well as coronary arteriolar and venular vasodilation. Nicorandil reduces the size of MI in irreversible ischemia and significantly improves postischemic myocardial stress with transient episodes of ischemia. Potassium channel activators increase myocardial tolerance to recurrent ischemic injury. single dose nicorandil - 40 mg, course of treatment - approximately 8 weeks.

Reducing the heart rate: a new approach to the treatment of angina pectoris. Heart rate, along with left ventricular contractility and workload, are key factors in determining myocardial oxygen consumption. Exercise-induced or pacing-induced tachycardia induces myocardial ischemia and appears to be the cause of the majority of coronary events in clinical practice. The channels through which sodium/potassium ions enter the cells of the sinus node were discovered in 1979. They are activated during the period of hyperpolarization of the cell membrane, are modified under the influence of cyclic nucleotides, and belong to the family of HCN channels. Catecholamines stimulate the activity of adenylate cyclase and the formation of cAMP, which promotes the opening of f-channels, an increase in heart rate. Acetylcholine has the opposite effect. The first drug to selectively interact with f-channels is ivabradine (coraxan , "Servier"), which selectively reduces the heart rate, but does not affect other electrophysiological properties of the heart and its contractility. It significantly slows down the diastolic depolarization of the membrane without changing the overall duration of the action potential. Reception schedule: 2.5, 5 or 10 mg twice a day for 2 weeks, then 10 mg twice a day for 2-3 months.

Antithrombotic drugs.

The likelihood of thrombus formation is reduced by thrombin inhibitors - direct ( hirudin ) or indirect (unfractionated heparin or low molecular weight heparins) and antiplatelet agents ( aspirin , thienopyridines, blockers of glycoprotein IIb / IIIa platelet receptors).

Heparins (unfractionated and low molecular weight). The use of unfractionated heparin (UFH) is recommended. Heparin is ineffective against platelet thrombus and has little effect on thrombin, which is part of the thrombus.

Low molecular weight heparins (LMWH) can be administered s / c, dosing them according to the patient's weight and without laboratory control.

Direct thrombin inhibitors. Application hirudina recommended for the treatment of patients with thrombocytopenia caused by heparin.

When treated with antithrombins, hemorrhagic complications may develop. Minor bleeding usually requires a simple discontinuation of treatment. Major bleeding from the gastrointestinal tract, manifested by vomiting of blood, chalky, or intracranial hemorrhage may require the use of heparin antagonists. This increases the risk of a thrombotic withdrawal phenomenon. The anticoagulant and hemorrhagic action of UFH is blocked by the administration of protamine sulfate , which neutralizes the anti-IIa activity of the drug. Protamine sulfate only partially neutralizes the anti-Xa activity of LMWH.

Antiplatelet agents. Aspirin (acetylsalicylic acid) inhibits cyclooxygenase-1 and blocks the formation of thromboxane A2. Thus, platelet aggregation induced through this pathway is suppressed.

Adenosine diphosphate receptor antagonists (thienopyridines). Thienopyridine derivatives ticlopidine and clopidogrel - antagonists of adenosine diphosphate, leading to inhibition of platelet aggregation. Their action comes more slowly than the action of aspirin. Clopidogrel has significantly fewer side effects than ticlopidine . Long-term use of a combination of clopidogrel and aspirin, started in the first 24 hours of ACS, is effective.

warfarin . Effective as a drug for the prevention of thrombosis and embolism warfarin . This drug is prescribed for patients with cardiac arrhythmias, patients who have had a myocardial infarction, suffering from chronic heart failure after surgical operations about prosthetics of large vessels and valves of the heart and in many other cases.

Dosing warfarin - very responsible medical manipulation. On the one hand, insufficient hypocoagulation (due to a low dose) does not save the patient from vascular thrombosis and embolism, and on the other hand, significant reduction coagulation activity increases the risk of spontaneous bleeding.

To monitor the state of the blood coagulation system, MHO is determined (International Normalized Ratio, derived from the prothrombin index). In accordance with the INR values, 3 levels of hypocoagulation intensity are distinguished: high (from 2.5 to 3.5), medium (from 2.0 to 3.0) and low (from 1.6 to 2.0). In 95% of patients, the MHO value is from 2.0 to 3.0. Periodic monitoring of MHO allows you to timely adjust the dose of the drug taken.

When appointed warfarin selection of an individual dose usually begins with 5 mg / day. After three days, the attending physician, focusing on the results of the INR, reduces or increases the amount of the drug taken and is re-assigned to the INR. This procedure can be continued 3-5 times before the necessary effective and safe dose is selected. So, with MHO less than 2, the dose of warfarin increases, with MHO more than 3, it decreases. Therapeutic latitude warfarin - from 1.25 mg/day to 10 mg/day.

Blockers of glycoprotein IIb/IIIa platelet receptors. This group of drugs (in particular, abciximab ) are highly effective for short-term intravenous administration in patients with ACS undergoing percutaneous coronary intervention (PCI) procedures.

Cytoprotective drugs.

A new approach in the treatment of coronary artery disease - myocardial cytoprotection, is to counteract the metabolic manifestations of ischemia. A new class of cytoprotectors - a metabolic drug trimetazidine , on the one hand, reduces the oxidation of fatty acids, and on the other hand, enhances oxidative reactions in mitochondria. As a result, there is a metabolic shift towards the activation of glucose oxidation.

Unlike drugs of the "hemodynamic" type (nitrates, beta-blockers, calcium antagonists), it has no restrictions for use in elderly patients with stable angina pectoris. Addendum trimetazidine to any traditional antianginal therapy can improve the clinical course of the disease, exercise tolerance and quality of life in elderly patients with stable exertional angina, while the use of trimetazidine was not accompanied by a significant effect on basic hemodynamic parameters and was well tolerated by patients.

Trimetazidine is produced in a new dosage form - trimetazidine MBi, 2 tablets per day, 35 mg each, which does not fundamentally differ in the mechanism of action from the trimetazidine 20 mg form, but has a number of valuable additional features. Trimetazidine MB , the first 3-CAT inhibitor, causes efficient and selective inhibition of the last enzyme in the beta-oxidation chain. The drug provides better protection of the myocardium from ischemia for 24 hours, especially in the early morning hours, since the new dosage form allows you to increase the value of the minimum concentration by 31% while maintaining the maximum concentration at the same level. The new dosage form makes it possible to increase the time during which the concentration of trimetazidine in the blood remains at a level not lower than 75% of the maximum, i.e. significantly increase the concentration plateau.

Another drug from the group of cytoprotectors - mildronate . It is a structural synthetic analog of gamma-butyrobetaine, a precursor of carnitine. It inhibits the enzyme gamma-butyrobetaine hydroxylase, reduces the synthesis of carnitine and the transport of long-chain fatty acids through cell membranes, and prevents the accumulation of activated forms of unoxidized fatty acids in cells (including acylcarnitine, which blocks the delivery of ATP to cell organelles). It has a cardioprotective, antianginal, antihypoxic, angioprotective effect. Improves myocardial contractility, increases exercise tolerance. In acute and chronic circulatory disorders, it contributes to the redistribution of blood flow to ischemic areas, thereby improving blood circulation in the focus of ischemia. With angina pectoris, 250 mg is prescribed orally 3 times / day for 3-4 weeks, it is possible to increase the dose to 1000 mg / day. In case of myocardial infarction, 500 mg - 1 g is administered intravenously once a day, after which they are switched to oral administration at a dose of 250 -500 mg 2 times / day for 3-4 weeks.

Coronaroplasty.

coronary revascularization. CHKB or coronary artery bypass grafting(CABG) in CAD is performed to treat recurrent (recurrent) ischemia and to prevent MI and death. Indications and choice of method of myocardial revascularization are determined by the degree and prevalence of arterial stenosis, angiographic characteristics of stenosis. In addition, it is necessary to take into account the capabilities and experience of the institution in carrying out both planned and emergency procedures.

Balloon angioplasty causes plaque rupture and may increase its thrombogenicity. This problem has been largely solved by the use of stents and blockers of glycoprotein IIb/IIIa platelet receptors. Mortality associated with PCI procedures is low in institutions with a high volume of procedures performed. Stent implantation in CAD can contribute to the mechanical stabilization of a ruptured plaque at the site of narrowing, especially in the presence of a plaque with a high risk of complications. After stent implantation, patients should take aspirin and within a month ticlopidine or clopidogrel . The combination of aspirin + clopidogrel is better tolerated and safer.

Coronary bypass. Operational mortality and the risk of infarction in CABG are currently low. These rates are higher in patients with severe unstable angina.

Atherectomy (rotational and laser) - removal of atherosclerotic plaques from a stenotic vessel by "drilling out" or destroying them with a laser. In different studies, survival after transluminal balloon angioplasty and rotational atherectomy differs, but without statistically significant differences.

Indications for percutaneous and surgical interventions.

Patients with single-vessel disease should usually undergo percutaneous angioplasty, preferably with stent placement in the presence of glycoprotein IIb/IIIa receptor blockers. Surgical intervention in such patients is advisable if the anatomy of the coronary arteries (severe tortuosity of the vessels or curvature) does not allow for safe PCI.

All patients with secondary prevention justified by aggressive and broad impact on risk factors. Stabilization of the patient's clinical condition does not mean stabilization of the underlying pathological process. Data on the duration of the healing process of a torn plaque are ambiguous. According to some studies, despite clinical stabilization against the background of drug treatment, stenosis, "responsible" for the exacerbation of coronary artery disease, retains a pronounced ability to progress.

Patients should stop smoking. When a diagnosis of IHD is made, lipid-lowering treatment should be started without delay (see section "Atheroxlerosis") with HMG-CoA reductase inhibitors ( statins ), which significantly reduce mortality and morbidity in patients with high and moderate levels of low-density lipoprotein (LDL) cholesterol. It is advisable to prescribe statins already during the first visit of the patient, using lipid levels in blood samples taken at admission as a guideline for dose selection. Target levels of total cholesterol and LDL cholesterol should be 5.0 and 3.0 mmol/l, respectively, but there is a point of view according to which a more pronounced decrease in LDL cholesterol should be sought. There are reasons to believe that ACE inhibitors can play a certain role in the secondary prevention of coronary artery disease. Since atherosclerosis and its complications are caused by many factors, in order to reduce the frequency of cardiovascular complications, special attention should be paid to the impact on all modifiable risk factors.

Prevention . Patients with risk factors for developing coronary artery disease need constant monitoring, systematic monitoring of the lipid profile, periodic ECG, timely and adequate treatment of concomitant diseases.

Treatment of coronary heart disease primarily depends on the clinical form. For example, although some general principles of treatment are used for angina pectoris and myocardial infarction, nevertheless, the tactics of treatment, the selection of an activity regimen and specific drugs can be fundamentally different. However, there are some general areas that are important for all forms of coronary artery disease.

1. Limitation of physical activity. During physical activity, the load on the myocardium increases, and as a result, the demand of the myocardium for oxygen and nutrients. If the blood supply to the myocardium is disturbed, this need is unsatisfied, which actually leads to manifestations of coronary artery disease. Therefore, the most important component of the treatment of any form of coronary artery disease is the limitation of physical activity and its gradual increase during rehabilitation.

2. Diet. With IHD, in order to reduce the load on the myocardium in the diet, the intake of water and sodium chloride is limited ( table salt). In addition, given the importance of atherosclerosis in the pathogenesis of CAD, great attention is given to limiting products that contribute to the progression of atherosclerosis. An important component CHD treatment is to combat obesity as a risk factor.

The following food groups should be limited, or if possible, avoided.

Animal fats (lard, butter, fatty meats)

Fried and smoked food.

Products containing a large number of salt (salted cabbage, salted fish, etc.)

Limit intake of high-calorie foods, especially fast-absorbing carbohydrates. (chocolate, sweets, cakes, pastry).

To correct body weight, it is especially important to monitor the ratio of energy coming from the food eaten, and energy consumption as a result of the body's activities. For stable weight loss, the deficit should be at least 300 kilocalories daily. The average person is unemployed physical work spends 2000-2500 kilocalories per day.

3. Pharmacotherapy for IHD. There are a number of groups of drugs that can be indicated for use in one form or another of coronary artery disease. In the US, there is a formula for the treatment of coronary artery disease: "A-B-C". It involves the use of a triad of drugs, namely antiplatelet agents, ?-blockers and hypocholesterolemic drugs.

Also, if there are concomitant hypertension, it is necessary to ensure the achievement of target blood pressure levels.

Antiplatelet agents (A). Antiplatelet agents prevent the aggregation of platelets and erythrocytes, reduce their ability to stick together and adhere to the vascular endothelium. Antiplatelet agents facilitate the deformation of erythrocytes when passing through the capillaries, improve blood flow.

Aspirin - taken 1 time per day at a dose of 100 mg, with suspicion of the development of myocardial infarction single dose can reach 500 mg.

Clopidogrel - taken 1 time per day, 1 tablet 75 mg. Mandatory admission within 9 months after endovascular interventions and CABG.

Adrenoblockers (B). Due to the action on β-arenoreceptors, adrenergic blockers reduce the heart rate and, as a result, myocardial oxygen consumption. Independent randomized trials confirm an increase in life expectancy when taking ?-blockers and a decrease in the frequency of cardiovascular events, including repeated ones. At present, it is not advisable to use the drug atenolol, since, according to randomized trials, it does not improve the prognosis. ?-blockers are contraindicated in concomitant pulmonary pathology, bronchial asthma, COPD. Below are the most popular?-blockers with proven properties to improve the prognosis in coronary artery disease.

Metoprolol (Betaloc Zok, Betaloc, Egiloc, Metocard, Vasocardin);

Bisoprolol (Concor, Coronal, Bisogamma, Biprol);

Carvedilol (Dilatrend, Talliton, Coriol).

Statins and Fibrates (C). Cholesterol-lowering drugs are used to reduce the rate of development of existing atherosclerotic plaques and prevent the occurrence of new ones. Proven positive influence life expectancy, and these drugs reduce the frequency and severity of cardiovascular events. The target cholesterol level in patients with coronary heart disease should be lower than in those without coronary artery disease, and equal to 4.5 mmol/l. The target level of LDL in patients with coronary artery disease is 2.5 mmol/l.

Lovastatin;

Simvastatin;

Atorvastatin;

Rosuvastatin (the only drug that significantly reduces the size of atherosclerotic plaque);

fibrates. They belong to a class of drugs that increase the anti-atherogenic fraction of HDL, with a decrease in which increases mortality from coronary artery disease. They are used to treat dyslipidemia IIa, IIb, III, IV, V. They differ from statins in that they mainly reduce triglycerides (VLDL) and can increase the HDL fraction. Statins predominantly lower LDL and do not significant influence for VLDL and HDL. Therefore, for maximum effective treatment macrovascular complications require a combination of statins and fibrates. With the use of fenofibrate, mortality from coronary artery disease is reduced by 25%. Of the fibrates, only fenofibrate is safely combined with any class of statin (FDA).

Fenofibrate

Other classes: omega-3 polyunsaturated fatty acid(Omacor). In IHD, they are used to restore the phospholipid layer of the cardiomyocyte membrane. By restoring the structure of the cardiomyocyte membrane, Omacor restores the basic (vital) functions of the cells of the heart - conductivity and contractility, which were impaired as a result of myocardial ischemia.

Nitrates. There are nitrates for injection.

The drugs in this group are derivatives of glycerol, triglycerides, diglycerides and monoglycerides. The mechanism of action is the influence of the nitro group (NO) on the contractile activity of vascular smooth muscles. Nitrates mainly act on the venous wall, reducing the preload on the myocardium (by expanding the vessels of the venous bed and depositing blood). side effect nitrates is to lower blood pressure and headaches. Nitrates are not recommended for use with blood pressure below 100/60 mm Hg. Art. In addition, it is now reliably known that nitrate intake does not improve the prognosis of patients with coronary artery disease, that is, it does not lead to an increase in survival, and is currently used as a drug to relieve symptoms of angina pectoris. Intravenous drip of nitroglycerin allows you to effectively deal with the symptoms of angina pectoris, mainly against the background of high blood pressure.

Nitrates exist in both injectable and tablet forms.

Nitroglycerine;

Isosorbide mononitrate.

Anticoagulants. Anticoagulants inhibit the appearance of fibrin threads, they prevent the formation of blood clots, help stop the growth of already existing blood clots, increase the effect of endogenous enzymes that destroy fibrin on blood clots.

Heparin (the mechanism of action is due to its ability to specifically bind to antithrombin III, which dramatically increases the inhibitory effect of the latter in relation to thrombin. As a result, blood coagulates more slowly).

Heparin is injected under the skin of the abdomen or using an intravenous infusion pump. Myocardial infarction is an indication for the appointment of heparin thromboprophylaxis, heparin is prescribed at a dose of 12500 IU, injected under the skin of the abdomen daily for 5-7 days. In the ICU, heparin is administered to the patient using an infusion pump. The instrumental criterion for prescribing heparin is the presence of S-T segment depression on the ECG, which indicates an acute process. This sign important in terms of differential diagnosis, for example, in cases where the patient has ECG signs of previous heart attacks.

Diuretics. Diuretics are designed to reduce the load on the myocardium by reducing the volume of circulating blood due to accelerated elimination body fluids.

Loopback. The drug "Furosemide" in tablet form.

Loop diuretics reduce the reabsorption of Na +, K +, Cl - in the thick ascending part of the loop of Henle, thereby reducing the reabsorption (reabsorption) of water. They have a fairly pronounced fast action, as a rule, they are used as emergency drugs (for forced diuresis).

The most common drug in this group is furosemide (Lasix). Exists in injection and tablet forms.

Thiazide. Thiazide diuretics are Ca2+ sparing diuretics. By decreasing the reabsorption of Na+ and Cl- in the thick segment of the ascending loop of Henle and primary department distal tubule of the nephron, thiazide drugs reduce urine reabsorption. With the systematic use of drugs of this group, the risk of cardiovascular complications in the presence of concomitant hypertension is reduced.

Hypothiazide;

Indapamide.

Angiotensin-converting enzyme inhibitors. By acting on the angiotensin-converting enzyme (ACE), this group of drugs blocks the formation of angiotensin II from angiotensin I, thus preventing the effects of angiotensin II, that is, leveling vasospasm. This ensures that the target blood pressure figures are maintained. The drugs of this group have a nephro- and cardioprotective effect.

Enalapril;

Lisinopril;

Captopril.

Antiarrhythmic drugs. The drug "Amiodarone" is available in tablet form.

Amiodarone belongs to III group antiarrhythmic drugs, has a complex antiarrhythmic action. This drug acts on Na + and K + channels of cardiomyocytes, and also blocks ?- and ?-adrenergic receptors. Thus, amiodarone has antianginal and antiarrhythmic effects. According to randomized clinical trials, the drug increases the life expectancy of patients who regularly take it. When taking tablet forms of amiodarone, the clinical effect is observed after approximately 2-3 days. Maximum effect achieved in 8-12 weeks. This is due to the long half-life of the drug (2-3 months). Concerning this drug It is used in the prevention of arrhythmias and is not a means of emergency care.

Given these properties of the drug, it is recommended following diagram its application. During the saturation period (the first 7-15 days), amiodarone is prescribed at a daily dose of 10 mg/kg of the patient's weight in 2-3 doses. With the onset of a persistent antiarrhythmic effect, confirmed by the results of daily ECG monitoring, the dose is gradually reduced by 200 mg every 5 days until a maintenance dose of 200 mg per day is reached.

Other groups of drugs.

Ethylmethylhydroxypyridine

The drug "Mexidol" in tablet form. Metabolic cytoprotector, antioxidant-antihypoxant, which has a complex effect on the key links of pathogenesis cardiovascular disease: anti-atherosclerotic, anti-ischemic, membrane-protective. Theoretically, ethylmethylhydroxypyridine succinate has a significant positive effect, but at present, there are no data on its clinical effectiveness based on independent randomized placebo-controlled trials.

Mexicor;

Coroner;

Trimetazidine.

4. The use of antibiotics for coronary artery disease. There are results clinical observations comparative efficacy of two different courses of antibiotics and placebo in patients admitted to the hospital with either acute myocardial infarction or unstable angina. Studies have shown the effectiveness of a number of antibiotics in the treatment of coronary artery disease. The effectiveness of this type of therapy is not pathogenetically substantiated, and this technique is not included in the standards for the treatment of coronary artery disease.

5. Endovascular coronary angioplasty. The use of endovascular (transluminal, transluminal) interventions (coronary angioplasty) in various forms of coronary artery disease is being developed. These interventions include balloon angioplasty and coronary angiography-guided stenting. In this case, the instruments are introduced through one of the large arteries(in most cases, the femoral artery is used), and the procedure is performed under fluoroscopy. In many cases, such interventions help prevent the development or progression of myocardial infarction and avoid open surgery.

This direction of treatment of coronary artery disease is engaged in a separate area of ​​cardiology - interventional cardiology.

6. Surgery.

Coronary artery bypass grafting is performed.

With certain parameters of coronary heart disease, there are indications for bypass surgery- an operation in which the blood supply to the myocardium is improved by connecting the coronary vessels below the site of their lesion with external vessels. The best known is coronary artery bypass grafting (CABG), in which the aorta is connected to segments of the coronary arteries. For this, autografts (usually the great saphenous vein) are often used as shunts.

It is also possible to use balloon dilatation of blood vessels. In this operation, the manipulator is inserted into the coronary vessels through a puncture of an artery (usually the femoral or radial), and through a balloon filled contrast agent the lumen of the vessel is expanded, the operation is, in fact, bougienage of the coronary vessels. Currently, “pure” balloon angioplasty without subsequent stent implantation is practically not used, due to low efficiency in the long-term period.

7. Other non-drug treatments

Hirudotherapy. Hirudotherapy is a method of treatment based on the use of antiplatelet properties of leeches saliva. This method is an alternative and has not been clinically tested for compliance. evidence-based medicine. Currently, it is used relatively rarely in Russia, it is not included in the standards of medical care for coronary artery disease, it is used, as a rule, at the request of patients. The potential positive effects of this method are the prevention of thrombosis. It should be noted that when treated according to approved standards, this task is performed using heparin prophylaxis.

Method shock wave therapy. The impact of shock waves of low power leads to myocardial revascularization.

An extracorporeal source of a focused acoustic wave allows you to influence the heart remotely, causing "therapeutic angiogenesis" (vascular formation) in the area of ​​myocardial ischemia. The impact of UVT has double effect- short-term and long-term. First, the vessels dilate, and blood flow improves. But the most important thing begins later - new vessels appear in the affected area, which provide a long-term improvement.

Low intensity shock waves induce shear stress in vascular wall. This stimulates the release of vascular growth factors, starting the process of growth of new vessels that feed the heart, improving myocardial microcirculation and reducing the effects of angina pectoris. The theoretical results of such treatment are a decrease in the functional class of angina pectoris, an increase in exercise tolerance, a decrease in the frequency of attacks and the need for drugs.

However, it should be noted that at present there have been no adequate independent multicenter randomized studies evaluating the effectiveness of this technique. Studies cited as evidence of the effectiveness of this technique are usually produced by the manufacturing companies themselves. Or do not meet the criteria of evidence-based medicine.

This method has not been widely used in Russia due to questionable efficiency, high cost of equipment, and lack of relevant specialists. In 2008, this method was not included in the standard of medical care for coronary artery disease, and these manipulations were performed on a contractual commercial basis, or in some cases under voluntary medical insurance contracts.

The use of stem cells. When using stem cells, those performing the procedure expect that the pluripotent stem cells introduced into the patient's body will differentiate into the missing cells of the myocardium or vascular adventitia. It should be noted that stem cells actually have this ability, but at present the level modern technologies does not allow differentiation of a pluripotent cell into the tissue we need. The cell itself makes a choice of the way of differentiation - and often not the one that is needed for the treatment of coronary artery disease.

This method of treatment is promising, but has not yet been clinically tested and does not meet the criteria of evidence-based medicine. It takes years scientific research to provide the effect that patients expect from the introduction of pluripotent stem cells.

Currently, this method of treatment is not used in official medicine and is not included in the standard of care for coronary artery disease.

quantum therapy ischemic heart disease. It is a therapy by exposure to laser radiation. The effectiveness of this method has not been proven, independent clinical trial was not carried out.

Ischemic heart disease is a pathological condition caused by a lack of nutrition of the heart muscle due to narrowing of the lumen of the coronary vessels or their spasm. It combines several diagnoses, such as angina pectoris, myocardial infarction, cardiosclerosis, sudden coronary death, and others.

Today it is the most common disease in its category in the world and ranks first among the causes of death and disability in all developed countries.

Predisposing factors

To date, criteria have been developed by which it is possible to predict the development of a particular disease. was no exception. There is not just a list, but a classification of risk factors, grouped according to a certain attribute, that can contribute to the occurrence of this disease.

1. Biological:
   - age over 50 years;
   - gender - men are more likely to get sick;
   - genetic predisposition to dysmetabolic diseases.
2. Anatomy:
   - high blood pressure;
   - obesity;
   - Availability diabetes.
3. Lifestyle:
   - violation of the diet;
   - smoking;
   - hypodynamia or excessive physical activity;
   - alcohol consumption.

Development of the disease

Pathogenetic causes of the development of the disease can be both extra- and intravascular problems, such as narrowing of the lumen of the coronary arteries due to atherosclerosis, thrombosis or spasm, or severe tachycardia with hypertension. But still, atherosclerosis is in the first place for the reasons for the development of a heart attack. Initially, a person develops a metabolic disorder, which is expressed in a persistent increase in blood lipids.

The next step is the fixation of lipid complexes in the walls of blood vessels and their perspiration inside the endothelial cells. Atherosclerotic plaques form. They destroy the wall of blood vessels, make it more fragile. At given state there can be two outcomes - either a thrombus breaks off from the plaque and clogs the artery upstream of the blood, or the diameter of the vessel becomes so small that the blood can no longer circulate freely and nourish a certain area. In this place, a focus of ischemia is formed, and then necrosis. If this whole process occurs in the heart, then the disease will be called coronary artery disease.

There are several clinical forms and their respective treatment for coronary artery disease. Drugs are selected based on the pathophysiological component.

Sudden coronary death

Otherwise known as cardiac arrest. It can have two outcomes: a person dies or ends up in intensive care. It is associated with sudden myocardial instability. This diagnosis is an exception when there is no reason to suspect another form of coronary artery disease. Treatment, drugs of choice for medical workers remain the same as in resuscitation. Another condition is that death must occur instantly and with witnesses or no later than six hours from the start heart attack. Otherwise, it already falls under another classification.

angina pectoris

This is one of the forms of IHD. It also has its own additional classification. So:

1. Stable angina pectoris.
2. Vasospastic angina.
3. Unstable angina, which, in turn, is divided into:
   - progressive;
   - first appeared;
   - early postinfarction.
4. Prinzmetal's angina.

The most common is the first type. The Association of Cardiologists has long developed the treatment of coronary artery disease for angina pectoris. Drugs must be taken regularly and for a long time, sometimes for life. If you follow the recommendations, then you can postpone unpleasant health consequences for some time.

myocardial infarction

It is established taking into account the data of the electrocardiogram, laboratory and anamnestic indicators. The most informative are the increases in such enzymes as LDH (lactate dehydrogenase), ALaT (alanine aminotransferase) and which are normally contained within the cell and appear in the blood only when it is destroyed.

A heart attack is one of the finals, which can lead to uncontrolled coronary heart disease. Treatment, drugs, help - all this can be late, because with acute attack very little time is allotted to reverse the damage.

Diagnostics

Naturally, any examination begins with a survey and examination. Collect history data. The doctor is interested in such complaints as chest pain after exercise, shortness of breath, fatigue, weakness, palpitations. It will be important to note the evening swelling, warm to the touch. And also how is the treatment of coronary artery disease. Drugs can tell a lot to the doctor. For example, "Nitroglycerin". If it helps to relieve an attack, then this almost always speaks in favor of angina pectoris.

The physical examination includes measuring pressure, breathing and pulse rate, and listening to the heart and lungs. The doctor tries to hear pathological murmurs, increased heart tones, as well as wheezing and blisters in the lungs, which would indicate congestive processes.

Treatment

Here we have moved on to the most basic. We are interested in the treatment of IHD. Drugs play a leading role in it, but not only they help to improve well-being. First of all, the patient needs to be explained that he will have to completely change his lifestyle. Remove excessive physical activity, balance sleep and rest, and eat well. Diet should be given special attention. It should contain potassium, calcium and sodium necessary for the heart, but at the same time limit the intake of salt, water, products with excess animal fats and carbohydrates. If a person has excess weight, it needs to be corrected.

But besides this, methods have been developed for the pharmacological elimination of such a problem as coronary heart disease. Treatment - drugs in the form of tablets, capsules, powders and solutions. With proper selection and regular use, you can achieve excellent results.

Antiplatelet agents

Groups of drugs for the treatment of coronary artery disease are divided into several classifications, but the most common - according to the mechanism of action. We will use it. Antiplatelet agents improve blood flow. They act on the coagulation and anticoagulation systems, somewhat uncoupling them, and thus achieve liquefaction. These include Aspirin, Clopidogrel, Warfarin and others. When prescribing them, it is always necessary to control the INR (international normalized ratio) in order to prevent a person from bleeding.

Beta blockers

They act on receptors in the walls of blood vessels, slowing down the heartbeat. As a result, it consumes less oxygen and needs less blood, which is very useful when narrowed. This is one of the most common drugs for coronary artery disease. Treatment, drugs of choice, and dose depend on the associated conditions. There are selective and non-selective beta-blockers. Some of them act more gently, others - a little harder, but absolute contraindication is the patient has a history of bronchial asthma or other obstructive pulmonary disease. Among the most common drugs are Biprolol, Visken, Carvedilol.

Statins

Doctors spend a lot of effort on the treatment of coronary artery disease. Drugs are being improved, new approaches are being developed, and studies are being carried out on the causes of the disease. One of these advanced approaches is to influence the precipitating factors, namely dyslipidemia or imbalance of blood fats. It has been proven that lowering cholesterol levels slows down the formation of atherosclerosis. And this is the main cause of IBS. Signs, treatment, drugs - all this has already been identified and developed, you just need to be able to use the available information for the benefit of the patient. Examples effective means can serve "Lovastatin", "Atorvastatin", "Simvastatin" and others.

Nitrates

The work of these drugs is one of the diagnostic signs that help confirm the presence of the disease. But they are also needed as part of a program that is included in the treatment of coronary artery disease. Medications and preparations are carefully selected, the dose and frequency of administration are adjusted. They affect the smooth muscles in the walls of blood vessels. Relaxing, these muscles increase the diameter of the lumen, thus increasing the amount of blood supplied. This helps to relieve ischemia and pain attack. But, unfortunately, nitrates cannot prevent the development of a heart attack in the global sense of the word, and does not increase life expectancy, therefore, it is recommended to take these drugs only during an attack (Dinisorb, Isoket), and on permanent basis choose something else.

Anticoagulants

If, in addition to angina pectoris, the patient has a threat of thrombosis, then these drugs for coronary artery disease are prescribed to him. Symptoms and treatment, drugs depend on how much this or that link of the pathological process prevails. One of the most famous means of this series is Heparin. It is administered in a large dose once in acute myocardial infarction, and then for several days the level in the blood plasma is maintained. It is necessary to carefully monitor the time of blood clotting.

Diuretics

Drugs for the treatment of coronary artery disease are not only pathogenetic, but also symptomatic. They affect such a link as high blood pressure. If you increase the amount of fluid that the body will lose, then you can artificially reduce the pressure to normal numbers and eliminate the threat of a second heart attack. But do not do it too quickly, so as not to provoke a collapse. There are several types of these drugs, depending on which part of the loop of Henle (section of the nephron) they affect. A competent doctor will select the medicine necessary in this situation. One that does not aggravate the patient's condition. Be healthy!

Treatment of IHD involves the joint work of the cardiologist and the patient in several areas at once. First of all, you need to take care of changing your lifestyle. In addition, drug treatment is prescribed, and, if necessary, surgical treatment methods are used.

Changing lifestyle and neutralizing risk factors include mandatory smoking cessation, correction of cholesterol levels (with the help of diet or medication), weight loss. Patients with IHD are recommended the so-called " mediterranean diet”, which includes vegetables, fruits, light poultry, fish and seafood dishes.

A very important point in the non-drug treatment of coronary artery disease is the fight against in a sedentary manner life by increasing physical activity sick. Of course, an indispensable condition for the successful treatment of IHD is preliminary treatment for hypertension or diabetes mellitus, if the development of IHD occurs against the background of these diseases.

The goals of coronary heart disease treatment are defined as improving the quality of life of the patient, that is, reducing the severity of symptoms, preventing the development of forms of coronary artery disease such as myocardial infarction, unstable angina, sudden cardiac death, and increasing the patient's life expectancy. The initial relief of an attack of angina pectoris is carried out with the help of nitroglycerin, which has a vasodilating effect. The rest of the drug treatment of coronary heart disease is prescribed only by a cardiologist, based on an objective picture of the disease. Among the drugs that are used in the treatment of coronary artery disease, one can single out drugs that help reduce myocardial oxygen demand, increase the volume of the coronary bed, etc. However, the main task in the treatment of coronary artery disease - to release the blocked vessels - is practically not solved with the help of medicines (in particular, sclerotic plaques are practically not destroyed by medicines). AT serious cases surgery will be required.

Aspirin has been considered a classic remedy for the treatment of coronary artery disease for many years, many cardiologists even recommend using it prophylactically in small quantities(half/one fourth tablet per day).

The modern level of cardiology has a diverse arsenal of medicines aimed at the treatment of various forms of coronary artery disease. However, only a cardiologist can prescribe any medications and they can only be used under the supervision of a doctor.

For more severe cases of CAD, use surgical methods treatment. Pretty good results are shown by coronary bypass surgery, when an artery blocked by a plaque or thrombus is replaced by an "artificial vessel" that takes over the conduction of blood flow. These operations are almost always performed on a non-working heart with cardiopulmonary bypass, after bypass surgery, the patient has to for a long time recover from extensive operating injury. The bypass method has many contraindications, especially in patients with a weakened body, but if the operation is successful, the results are usually good.

The most promising treatment for coronary artery disease in this moment considered endovascular surgery (X-ray surgery). The term "endovascular" is translated as "inside the vessel." This relatively young branch of medicine has already won a strong position in the treatment of coronary artery disease. All interventions are carried out without incisions, through punctures in the skin, under x-ray supervision, for the operation it is enough local anesthesia. All these features are most important for those patients for whom, due to concomitant diseases, or because of the general weakness of the body, traditional therapy is contraindicated. surgical intervention. Of the methods of endovascular surgery for IHD, balloon angioplasty and stenting are most often used, which allow restoring patency in arteries affected by ischemia. When using balloon angioplasty, a special balloon is inserted into the vessel, and then it swells up and “pushes” atherosclerotic plaques or blood clots to the sides. After that, a so-called stent is inserted into the artery - a mesh tubular frame made of "medical" stainless steel or alloys of biologically inert metals, capable of expanding independently and maintaining the shape given to the vessel.

Treatment of coronary heart disease primarily depends on the clinical form. For example, although some general principles of treatment are used for angina pectoris and myocardial infarction, nevertheless, the tactics of treatment, the selection of an activity regimen and specific drugs can be fundamentally different. However, there are some general areas that are important for all forms of coronary artery disease.

• 1. Limitation of physical activity. During physical activity, the load on the myocardium increases, and as a result, the demand of the myocardium for oxygen and nutrients increases. If the blood supply to the myocardium is disturbed, this need is unsatisfied, which actually leads to manifestations of coronary artery disease. Therefore, the most important component of the treatment of any form of coronary artery disease is the limitation of physical activity and its gradual increase during rehabilitation.
• 2. Diet. With IHD, in order to reduce the load on the myocardium in the diet, the intake of water and sodium chloride (salt) is limited. In addition, given the importance of atherosclerosis in the pathogenesis of coronary artery disease, much attention is paid to limiting foods that contribute to the progression of atherosclerosis. An important component of the treatment of coronary artery disease is the fight against obesity as a risk factor.

The following food groups should be limited, or if possible, avoided.

• Animal fats (lard, butter, fatty meats)
• · Fried and smoked food.
• Products containing a large amount of salt (salted cabbage, salted fish, etc.)
• Limit intake of high-calorie foods, especially fast-absorbing carbohydrates. (chocolate, sweets, cakes, pastry).

To correct body weight, it is especially important to monitor the ratio of energy coming from the food eaten, and energy consumption as a result of the body's activities. For stable weight loss, the deficit should be at least 300 kilocalories daily. On average, a person who is not engaged in physical work spends 2000-2500 kilocalories per day.

3. Pharmacotherapy for IHD. There are a number of groups of drugs that can be indicated for use in one form or another of coronary artery disease. In the US, there is a formula for the treatment of coronary artery disease: "A-B-C". It involves the use of a triad of drugs, namely antiplatelet agents, β-blockers and hypocholesterolemic drugs.

Also, in the presence of concomitant hypertension, it is necessary to ensure the achievement of target levels of blood pressure.

• - Antiplatelet agents (A). Antiplatelet agents prevent the aggregation of platelets and erythrocytes, reduce their ability to stick together and adhere to the vascular endothelium. Antiplatelet agents facilitate the deformation of erythrocytes when passing through the capillaries, improve blood flow.
• Aspirin - taken once a day at a dose of 100 mg, if myocardial infarction is suspected, a single dose can reach 500 mg.
• Clopidogrel - taken once a day, 1 tablet 75 mg. Mandatory admission within 9 months after endovascular interventions and CABG.
• - β-blockers (B). Due to the action on β-arenoreceptors, blockers reduce heart rate and, as a result, myocardial oxygen consumption. Independent randomized trials confirm an increase in life expectancy when taking β-blockers and a decrease in the frequency of cardiovascular events, including repeated ones. At present, it is not advisable to use the drug atenolol, since, according to randomized trials, it does not improve the prognosis. β-blockers are contraindicated in concomitant pulmonary pathology, bronchial asthma, COPD. The following are the most popular β-blockers with proven prognostic properties in coronary artery disease.
• Metoprolol (Betaloc Zok, Betaloc, Egiloc, Metocard, Vasocardin);
• bisoprolol (Concor, Coronal, Bisogamma, Biprol);
• Carvedilol (Dilatrend, Talliton, Coriol).
• - Statins and Fibrates (C). Cholesterol-lowering drugs are used to reduce the rate of development of existing atherosclerotic plaques and prevent the occurrence of new ones. These drugs have been proven to have a positive effect on life expectancy, and these drugs reduce the frequency and severity of cardiovascular events. The target cholesterol level in patients with coronary heart disease should be lower than in those without coronary artery disease, and equal to 4.5 mmol/l. The target level of LDL in patients with IHD is 2.5 mmol/l.
• lovastatin;
• simvastatin;
• atorvastatin;
• Rosuvastatin (the only drug that significantly reduces the size of atherosclerotic plaque);

fibrates. They belong to a class of drugs that increase the anti-atherogenic fraction of HDL, with a decrease in which increases mortality from coronary artery disease. They are used to treat dyslipidemia IIa, IIb, III, IV, V. They differ from statins in that they mainly reduce triglycerides (VLDL) and can increase the HDL fraction. Statins predominantly lower LDL and do not significantly affect VLDL and HDL. Therefore, for the most effective treatment of macrovascular complications, a combination of statins and fibrates is required. With the use of fenofibrate, mortality from coronary artery disease is reduced by 25%. Of the fibrates, only fenofibrate is safely combined with any class of statin (FDA).

fenofibrate

Other classes: omega-3 polyunsaturated fatty acids (Omacor). In IHD, they are used to restore the phospholipid layer of the cardiomyocyte membrane. By restoring the structure of the cardiomyocyte membrane, Omacor restores the basic (vital) functions of the heart cells - conductivity and contractility, which were impaired as a result of myocardial ischemia.

Nitrates. There are nitrates for injection.

The drugs in this group are derivatives of glycerol, triglycerides, diglycerides and monoglycerides. The mechanism of action is the influence of the nitro group (NO) on the contractile activity of vascular smooth muscles. Nitrates mainly act on the venous wall, reducing the preload on the myocardium (by expanding the vessels of the venous bed and depositing blood). A side effect of nitrates is a decrease in blood pressure and headaches. Nitrates are not recommended for use with blood pressure below 100/60 mm Hg. Art. In addition, it is now reliably known that nitrate intake does not improve the prognosis of patients with coronary artery disease, that is, it does not lead to an increase in survival, and is currently used as a drug to relieve symptoms of angina pectoris. Intravenous drip of nitroglycerin allows you to effectively deal with the symptoms of angina pectoris, mainly against the background of high blood pressure.

Nitrates exist in both injectable and tablet forms.

• nitroglycerin;
• isosorbide mononitrate.

Anticoagulants. Anticoagulants inhibit the appearance of fibrin threads, they prevent the formation of blood clots, help stop the growth of already existing blood clots, increase the effect of endogenous enzymes that destroy fibrin on blood clots.

Heparin (the mechanism of action is due to its ability to specifically bind to antithrombin III, which dramatically increases the inhibitory effect of the latter in relation to thrombin. As a result, blood coagulates more slowly).

Heparin is injected under the skin of the abdomen or using an intravenous infusion pump. Myocardial infarction is an indication for the appointment of heparin thromboprophylaxis, heparin is prescribed at a dose of 12500 IU, injected under the skin of the abdomen daily for 5-7 days. In the ICU, heparin is administered to the patient using an infusion pump. The instrumental criterion for prescribing heparin is the presence of S-T segment depression on the ECG, which indicates an acute process. This symptom is important in terms of differential diagnosis, for example, in cases where the patient has ECG signs of previous heart attacks.

Diuretics. Diuretics are designed to reduce the load on the myocardium by reducing the volume of circulating blood due to the accelerated removal of fluid from the body.

Loopback. The drug "Furosemide" in tablet form.

Loop diuretics reduce the reabsorption of Na + , K + , Cl - in the thick ascending part of the loop of Henle, thereby reducing the reabsorption (reabsorption) of water. They have a fairly pronounced fast action, as a rule, they are used as emergency drugs (for forced diuresis).

The most common drug in this group is furosemide (Lasix). Exists in injection and tablet forms.

Thiazide. Thiazide diuretics are Ca 2+ sparing diuretics. By reducing the reabsorption of Na + and Cl - in the thick segment of the ascending loop of Henle and the initial section of the distal nephron tubule, thiazide drugs reduce urine reabsorption. With the systematic use of drugs of this group, the risk of cardiovascular complications in the presence of concomitant hypertension is reduced.

• hypothiazide;
• indapamide.

Angiotensin-converting enzyme inhibitors. By acting on the angiotensin-converting enzyme (ACE), this group of drugs blocks the formation of angiotensin II from angiotensin I, thus preventing the effects of angiotensin II, that is, leveling vasospasm. This ensures that the target blood pressure figures are maintained. The drugs of this group have a nephro- and cardioprotective effect.

• enalapril;
• lisinopril;
• captopril.

Antiarrhythmic drugs. The drug "Amiodarone" is available in tablet form.

Amiodarone belongs to the III group of antiarrhythmic drugs, has a complex antiarrhythmic effect. This drug acts on Na + and K + channels of cardiomyocytes, and also blocks b- and b-adrenergic receptors. Thus, amiodarone has antianginal and antiarrhythmic effects. According to randomized clinical trials, the drug increases the life expectancy of patients who regularly take it. When taking tablet forms of amiodarone, the clinical effect is observed after approximately 2-3 days. The maximum effect is achieved after 8-12 weeks. This is due to the long half-life of the drug (2-3 months). In this regard, this drug is used in the prevention of arrhythmias and is not a means of emergency care.

Taking into account these properties of the drug, the following scheme of its use is recommended. During the saturation period (the first 7-15 days), amiodarone is prescribed at a daily dose of 10 mg/kg of the patient's weight in 2-3 doses. With the onset of a persistent antiarrhythmic effect, confirmed by the results of daily ECG monitoring, the dose is gradually reduced by 200 mg every 5 days until a maintenance dose of 200 mg per day is reached.

Other groups of drugs.

Ethylmethylhydroxypyridine

The drug "Mexidol" in tablet form. Metabolic cytoprotector, antioxidant-antihypoxant, which has a complex effect on the key links in the pathogenesis of cardiovascular disease: anti-atherosclerotic, anti-ischemic, membrane-protective. Theoretically, ethylmethylhydroxypyridine succinate has a significant positive effect, but at present, there are no data on its clinical effectiveness based on independent randomized placebo-controlled trials.

• · Mexicor;
• The coronator
• trimetazidine.
• 4. The use of antibiotics in IHD. There are clinical observations of the comparative efficacy of two different courses of antibiotics and placebo in patients admitted to the hospital with either acute myocardial infarction or unstable angina. Studies have shown the effectiveness of a number of antibiotics in the treatment of coronary artery disease. The effectiveness of this type of therapy is not pathogenetically substantiated, and this technique is not included in the standards for the treatment of coronary artery disease.
• 5. Endovascular coronary angioplasty. The use of endovascular (transluminal, transluminal) interventions (coronary angioplasty) in various forms of coronary artery disease is being developed. These interventions include balloon angioplasty and coronary angiography-guided stenting. In this case, the instruments are inserted through one of the large arteries (in most cases, the femoral artery is used), and the procedure is performed under the control of fluoroscopy. In many cases, such interventions help prevent the development or progression of myocardial infarction and avoid open surgery.

This direction of treatment of coronary artery disease is engaged in a separate area of ​​cardiology - interventional cardiology.

6. Surgical treatment.

Coronary artery bypass grafting is performed.

With certain parameters of coronary heart disease, there are indications for coronary bypass surgery - an operation in which the blood supply to the myocardium is improved by connecting the coronary vessels below the site of their lesion with external vessels. The best known is coronary artery bypass grafting (CABG), in which the aorta is connected to segments of the coronary arteries. For this, autografts (usually the great saphenous vein) are often used as shunts.

It is also possible to use balloon dilatation of blood vessels. In this operation, the manipulator is introduced into the coronary vessels through a puncture of the artery (usually the femoral or radial), and the vessel lumen is expanded by means of a balloon filled with a contrast agent, the operation is, in fact, coronary vessel bougienage. Currently, “pure” balloon angioplasty without subsequent stent implantation is practically not used, due to low efficiency in the long-term period.

• 7. Other non-drug treatments
• - Hirudotherapy. Hirudotherapy is a method of treatment based on the use of antiplatelet properties of leeches saliva. This method is an alternative and has not been clinically tested for compliance with the requirements of evidence-based medicine. Currently, it is used relatively rarely in Russia, it is not included in the standards of medical care for coronary artery disease, it is used, as a rule, at the request of patients. The potential positive effects of this method are the prevention of thrombosis. It should be noted that when treated according to approved standards, this task is performed using heparin prophylaxis.
• - The method of shock wave therapy. The impact of shock waves of low power leads to myocardial revascularization.

An extracorporeal source of a focused acoustic wave allows you to influence the heart remotely, causing "therapeutic angiogenesis" (vascular formation) in the area of ​​myocardial ischemia. Exposure to UVT has a double effect - short-term and long-term. First, the vessels dilate, and blood flow improves. But the most important thing begins later - new vessels appear in the affected area, which provide a long-term improvement.

Low-intensity shock waves induce shear stress in the vascular wall. This stimulates the release of vascular growth factors, starting the process of growth of new vessels that feed the heart, improving myocardial microcirculation and reducing the effects of angina pectoris. The theoretical results of such treatment are a decrease in the functional class of angina pectoris, an increase in exercise tolerance, a decrease in the frequency of attacks and the need for drugs.

However, it should be noted that at present there have been no adequate independent multicenter randomized studies evaluating the effectiveness of this technique. Studies cited as evidence of the effectiveness of this technique are usually produced by the manufacturing companies themselves. Or do not meet the criteria of evidence-based medicine.

This method has not been widely used in Russia due to questionable efficiency, high cost of equipment, and lack of relevant specialists. In 2008, this method was not included in the standard of medical care for coronary artery disease, and these manipulations were performed on a contractual commercial basis, or in some cases under voluntary medical insurance contracts.

- Use of stem cells. When using stem cells, those performing the procedure expect that the pluripotent stem cells introduced into the patient's body will differentiate into the missing cells of the myocardium or vascular adventitia. It should be noted that stem cells actually have this ability, but at present the level of modern technologies does not allow us to differentiate a pluripotent cell into the tissue we need. The cell itself makes the choice of the path of differentiation - and often not the one that is needed for the treatment of coronary artery disease.

This method of treatment is promising, but has not yet been clinically tested and does not meet the criteria of evidence-based medicine. Years of scientific research are required to provide the effect that patients expect from the introduction of pluripotent stem cells.

Currently, this method of treatment is not used in official medicine and is not included in the standard of care for coronary artery disease.

- Quantum therapy for coronary artery disease. It is a therapy by exposure to laser radiation. The effectiveness of this method has not been proven, an independent clinical study has not been conducted.

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ATconducting

The heart is one of the main human organs. This is our engine that works without rest, and if earlier, failures in its operation were observed in older people, then recently heart disease has become much younger and is at the top of the list of life-threatening diseases.

Relevance.In spite of modern achievements medicine, the last decade is characterized by a steady increase in cardiovascular diseases in the population. Atherosclerosis, coronary heart disease, hypertension and their complications have come to the fore among the causes of morbidity, disability, disability and mortality in economically developed countries. In Russia, the annual mortality from cardiovascular causes exceeds one million people. Myocardial infarction develops in 0.9-1.4% of men aged 40-59 years, in men of the older age group - 2.1% per year. There is a steady increase in the incidence among young and middle-aged people. Despite the decrease in hospital mortality, the overall mortality from this disease remains high, reaching 40-60%. It should be noted that most of lethal outcomes occurs at the prehospital stage.

Numerous epidemiological studies have revealed a significant prevalence of arterial hypertension among the adult population. In the EU countries, the number of patients with high blood pressure reaches 20-30%, in Russia - 30-40%. arterial hypertension is one of the main risk factors for coronary heart disease, cerebral stroke, heart failure. These circumstances determine the great importance of the introduction of new achievements in cardiology in practical health care.

Targetwork- to study the basic modern principles of the treatment of coronary heart disease.

1. IshamandcheskyboleznWitheheart

(IHD; lat. morbus ischaemicus cordis from other Greek. ?uchsch - “I hold back, hold back” and b?mb - “blood”) -- pathological condition, characterized by an absolute or relative violation of the blood supply to the myocardium due to damage to the coronary arteries.

Coronary artery disease is a myocardial disorder caused by a disorder of the coronary circulation resulting from an imbalance between the coronary blood flow and the metabolic needs of the heart muscle. In other words, the myocardium needs more oxygen than it comes from the blood. IHD can occur acutely (in the form of myocardial infarction), as well as chronically (periodic attacks of angina pectoris).

IHD is a very common disease, one of the main causes of death, as well as temporary and permanent disability in the developed countries of the world. In this regard, the problem of IHD occupies one of the leading places among the most important medical problems XXI century.

In the 80s. there was a tendency to reduce mortality from coronary artery disease, but nevertheless in the developed countries of Europe it accounted for about half of the total mortality of the population, while maintaining a significant uneven distribution among the contingents of people of different sex and age. In the USA in the 80s. the death rate for men aged 35-44 was about 60 per 100,000 of the population, and the ratio of dead men and women at this age was approximately 5:1. By the age of 65-74 years, the total mortality from coronary artery disease of both sexes reached more than 1600 per 100,000 of the population, and the ratio between dead men and women in this age group decreased to 2:1.

The fate of patients with coronary artery disease, which make up a significant part of the contingent observed by doctors, largely depends on the adequacy of the ongoing outpatient treatment, on the quality and timeliness of diagnosis of those clinical forms of the disease that require emergency care or urgent hospitalization for the patient.

According to statistics in Europe, CHD and cerebral stroke determine 90% of all diseases of the cardiovascular system, which characterizes CHD as one of the most common diseases.

1.1 Etiologyandpathogenesis

A number of factors contribute to the occurrence of IHD. Among them, the first place should be given to hypertension, which is detected in 70% of patients with coronary artery disease. Hypertension contributes to more rapid development atherosclerosis and spasm of the coronary arteries of the heart. A predisposing factor to the occurrence of coronary artery disease is also diabetes mellitus, which contributes to the development of atherosclerosis due to impaired protein and lipid metabolism. When smoking, a spasm of the coronary vessels develops, as well as blood clotting increases, which contributes to the occurrence of thrombosis of the altered coronary vessels. Genetic factors are of some importance. It has been established that if parents suffer from coronary artery disease, then their children have it 4 times more often than those whose parents are healthy. Hypercholesterolemia significantly increases the likelihood of coronary artery disease, since it is one of the important factors contributing to the development of atherosclerosis in general and coronary vessels in particular. In obesity, coronary artery disease occurs several times more often than in people with normal body weight. In patients with obesity, the amount of cholesterol in the blood is increased, in addition, these patients lead a sedentary lifestyle, which also contributes to the development of atherosclerosis and coronary artery disease.

IHD is one of the most common diseases in industrialized countries. Over the past 30 years, the incidence of coronary artery disease has doubled, which is associated with mental stress. In men, coronary artery disease appears about 10 years earlier than in women. faces physical labor get sick less often than people of mental labor.

1.2 Pathologicalanatomy

Pathological and anatomical changes depend on the degree of damage to the coronary vessels by atherosclerosis. With angina pectoris, when there is no myocardial infarction, only small foci of cardiosclerosis are noted. At least 50% of the area of ​​the lumen of one of the coronary vessels must be affected in order to develop angina pectoris. Angina pectoris is especially difficult if two or three coronary vessels are affected simultaneously. With myocardial infarction, necrosis of muscle fibers occurs already in the first 5-6 hours after a painful attack. 8-10 days after myocardial infarction, a large number of newly formed capillaries appear. Since that time, connective tissue has rapidly developed in areas of necrosis. From this moment, scarring begins in the areas of necrosis. After 3-4 months.

1.3 Symptomsandsignsischemicdiseasehearts

The first signs of IHD, as a rule, are painful sensations - that is, the signs are purely subjective. The reason for going to the doctor should be any unpleasant sensation in the region of the heart, especially if it is unfamiliar to the patient. Suspicion of coronary artery disease should arise in a patient even if pain in the retrosternal region occurs during physical or emotional stress and passes at rest, they have the nature of an attack.

The development of coronary artery disease lasts for decades, during the progression of the disease, its forms may change and, accordingly, clinical manifestations and symptoms. Therefore, we will consider the most common symptoms of coronary artery disease. However, it should be noted that about one third of patients with coronary artery disease may not experience any symptoms of the disease at all, and may not even be aware of its existence. Others may experience CHD symptoms such as pain in the chest, in the left arm, in the lower jaw, in the back, shortness of breath, nausea, excessive sweating, palpitations or heart rhythm disturbances.

As for the symptoms of such a form of coronary artery disease as sudden cardiac death: a few days before an attack, a person develops paroxysmal discomfort behind the sternum, psycho-emotional disorders are often observed, fear imminent death. Symptoms sudden cardiac death: loss of consciousness, respiratory arrest, lack of pulse on large arteries (carotid and femoral); absence of heart sounds; pupil dilation; the appearance of a pale gray skin tone. During an attack, which often occurs at night in a dream, 120 seconds after it begins, brain cells begin to die. After 4-6 minutes, irreversible changes in the central nervous system occur. After about 8-20 minutes, the heart stops and death occurs.

2. Classificationischemic heart disease

1.sudden cardiac death(primary cardiac arrest, coronary death) is the most severe, lightning-fast clinical variant of IHD. It is IHD that is the cause of 85-90% of all cases of sudden death. Sudden cardiac death includes only those cases of sudden cessation of cardiac activity, when death occurs with witnesses within an hour after the onset of the first threatening symptoms. At the same time, before the onset of death, the condition of the patients was assessed as stable and not causing concern.

Sudden cardiac death can be triggered by excessive physical or mental stress, as it can also occur at rest, for example, in sleep. Immediately before the onset of sudden cardiac death, about half of the patients have a pain attack, which is often accompanied by fear of imminent death. Most often, sudden cardiac death occurs in an out-of-hospital setting, which determines the most frequent fatal outcome this form of IHD.

2.angina pectoris (angina pectoris) is the most common form of IHD. Angina pectoris is an attack of sudden onset and usually quickly disappearing chest pain. The duration of an angina attack ranges from a few seconds to 10-15 minutes. The pain most often occurs during physical exertion, such as walking. This is the so-called angina pectoris. Less commonly, it occurs during mental work, after emotional overload, during cooling, after a heavy meal, etc. Depending on the stage of the disease, angina pectoris is divided into new-onset angina, stable angina (indicating the functional class from I to IV), and progressive angina. With the further development of coronary artery disease, angina pectoris is supplemented by rest angina, in which pain attacks occur not only during exertion, but also at rest, sometimes at night.

3.heart attack myocardium- a formidable disease in which a protracted attack of angina pectoris can pass. This form of coronary artery disease is caused by acute insufficiency of blood supply to the myocardium, which causes a focus of necrosis, that is, tissue necrosis, to occur in it. The main cause of myocardial infarction is a complete or almost complete blockage of the arteries by a thrombus or swollen atherosclerotic plaque. With complete blockage of the artery by a thrombus, the so-called macrofocal (transmural) myocardial infarction occurs. If the blockage of the artery is partial, then several smaller foci of necrosis develop in the myocardium, then they speak of a small-focal myocardial infarction.

Another form of manifestation of IHD is called postinfarction cardiosclerosis. Postinfarction cardiosclerosis occurs as a direct consequence of myocardial infarction.

Postinfarction cardiosclerosis- this is a lesion of the heart muscle, and often the valves of the heart, due to the development of scar tissue in them in the form of areas of various sizes and prevalence, replacing the myocardium. Postinfarction cardiosclerosis develops because the dead areas of the heart muscle are not restored, but are replaced by scar tissue. Manifestations of cardiosclerosis often become conditions such as heart failure and various arrhythmias.

The main manifestations of cardiosclerosis are signs of heart failure and arrhythmias. The most noticeable symptom of heart failure is pathological dyspnea that occurs with minimal exertion, and sometimes even at rest. In addition, signs of heart failure can include increased heart rate, increased fatigue, and swelling caused by excess fluid retention in the body. unifying different kinds an arrhythmia symptom is an unpleasant sensation associated with the fact that the patient feels his heart beat. In this case, the heartbeat may be rapid (tachycardia), slowed down (bradycardia), the heart may beat intermittently, etc.

It should be recalled once again that coronary disease develops in a patient for many years, and the sooner a correct diagnosis is made and appropriate treatment is started, the more chances a patient has for a full life in the future.

Painless ischemia myocardial infarction is the most unpleasant and dangerous type of coronary artery disease, since, unlike angina attacks, episodes of painless ischemia proceed unnoticed by the patient. Therefore, 70% of cases of sudden cardiac death occur in patients with silent myocardial ischemia. In addition, painless ischemia increases the risk of arrhythmias and congestive heart failure. Only a cardiologist can detect painless ischemia in a patient using such research methods as long-term Holter monitoring, functional stress tests, echocardiography. In the case of timely examination and correct diagnosis, painless myocardial ischemia is successfully treated.

3. Diagnosticsischemicdiseasehearts

ischemic heart disease stroke

The correct diagnosis of coronary heart disease can only be made by a cardiologist using modern methods diagnostics. So high percent mortality from coronary artery disease in the 20th century is partly due to the fact that due to the abundance variety of symptoms and frequent cases of asymptomatic CHD, staging correct diagnosis was difficult. In our time, medicine has made a huge step forward in the methods of diagnosing coronary artery disease.

Interview patient

Of course, any diagnosis begins with a survey of the patient. The patient needs to remember as accurately as possible all the sensations in the region of the heart that he experiences and experienced before, to determine whether they have changed or remained unchanged for a long time, whether he has symptoms such as shortness of breath, dizziness, palpitations, etc. In addition, the doctor should be interested in what diseases the patient has suffered during his life, what medications he usually takes, and much more.

Inspection patient

During the examination, the cardiologist listens possible noise in the heart, determines if the patient has swelling or blueness (symptoms of heart failure)

Laboratory research

During laboratory tests, the level of cholesterol and sugar in the blood is determined, as well as enzymes that appear in the blood during a heart attack and unstable angina.

Electrocardiogram

One of the main methods for diagnosing all cardiovascular diseases, including coronary artery disease, is electrocardiography. The method of recording an electrocardiogram is widely used in cardiological diagnostics and is an obligatory step in examining a patient, regardless of preliminary diagnosis. An ECG is also used for dispensary examinations, for preventive medical examinations, and for tests with physical activity (for example, on a bicycle ergometer). With regard to the role of the ECG in the recognition of coronary artery disease, this examination helps to detect abnormalities in the modes of operation of the heart muscle, which can be crucial for the diagnosis of coronary artery disease.

Holter monitoring ECG

Holter monitoring of the electrocardiogram is a long-term, often daily ECG recording, which is performed offline in a hospital or outpatient setting. At the same time, the conditions for conducting the examination should be as close as possible to the daily life of the patient, both at rest and during a variety of physical and psychological stress. This allows you to register not only the symptoms of coronary artery disease, but also the conditions, the causes of their occurrence (at rest, during exercise). Holter monitoring helps the cardiologist determine the level of load at which the attack begins, after what time of rest it ends, and also to identify rest angina attacks, which often occur at night. Thus, a reliable picture of a person's condition is created for a more or less long time, episodes of ischemia, cardiac arrhythmias are detected.

Load tests

Electrocardiographic stress tests are also an indispensable method for diagnosing angina pectoris. The essence of the method is ECG registration during the performance of the patient dosed physical activity. With physical activity, selected for each patient individually, conditions are created that require a high supply of oxygen to the myocardium: it is these conditions that will help to identify the discrepancy between the metabolic needs of the myocardium and the ability of the coronary arteries to provide sufficient blood supply to the heart. In addition, ECG exercise tests can also be used to detect coronary insufficiency in individuals who do not present any complaints, for example, with painless myocardial ischemia. The most popular of them and the most commonly used can be considered a bicycle ergometric test, which allows you to accurately dose muscle work in a wide power range.

Functional samples

In addition, for the diagnosis of coronary artery disease are sometimes used functional tests that provoke spasm of the coronary artery. This is a cold test and a test with ergometrine. However, the first one gives reliable results only in 15-20% of cases, and the second can be dangerous for the development of severe complications, and therefore these methods are used only in specialized research institutions.

ultrasonic study hearts. echocardiography

AT last years has become very common ultrasound procedure heart - echocardiography. EchoCG makes it possible to interpret the acoustic phenomena of the beating heart, to obtain important diagnostic signs in most cardiac diseases, including those with IBS. For example, EchoCG reveals the degree of dysfunction of the heart, changes in the size of the cavities, the condition of the heart valves. In some patients, violations of myocardial contractility are not determined at rest, but occur only under conditions increased load to the myocardium. In these cases, stress echocardiography is used - a technique for ultrasound of the heart, in which myocardial ischemia induced by various stress agents (eg, dosed physical activity) is recorded.

4. Modernmethodstreatmentischemicdiseasehearts

Treatment of IHD involves the joint work of the cardiologist and the patient in several areas at once. First of all, you need to take care of changing your lifestyle. In addition, drug treatment is prescribed, and, if necessary, surgical treatment methods are used.

Changing lifestyle and neutralizing risk factors include mandatory smoking cessation, correction of cholesterol levels (with the help of diet or medication), weight loss. Patients with coronary artery disease are recommended the so-called "Mediterranean diet", which includes vegetables, fruits, light dishes from poultry, fish and seafood.

A very important point in the non-drug treatment of coronary artery disease is the fight against a sedentary lifestyle by increasing the physical activity of the patient. Of course, an indispensable condition for the successful treatment of IHD is preliminary treatment for hypertension or diabetes mellitus, if the development of IHD occurs against the background of these diseases.

The goals of coronary heart disease treatment are defined as improving the quality of life of the patient, that is, reducing the severity of symptoms, preventing the development of forms of coronary artery disease such as myocardial infarction, unstable angina, sudden cardiac death, and increasing the patient's life expectancy. The initial relief of an attack of angina pectoris is carried out with the help of nitroglycerin, which has a vasodilating effect. The rest of the drug treatment of coronary heart disease is prescribed only by a cardiologist, based on an objective picture of the disease. Among the drugs that are used in the treatment of coronary artery disease, one can single out drugs that help reduce myocardial oxygen demand, increase the volume of the coronary bed, etc. However, the main task in the treatment of coronary artery disease - to release the blocked vessels - is practically not solved with the help of medicines (in particular, sclerotic plaques are practically not destroyed by medicines). In severe cases, surgery will be required.

For many years, aspirin has been considered a classic remedy for the treatment of coronary artery disease, many cardiologists even recommend using it prophylactically in small quantities (half/one-fourth of a tablet a day).

The modern level of cardiology has a diverse arsenal of medicines aimed at the treatment of various forms of coronary artery disease. However, only a cardiologist can prescribe any medications and they can only be used under the supervision of a doctor.

In more severe cases of coronary artery disease, surgical methods of treatment are used. Pretty good results are shown by coronary bypass surgery, when an artery blocked by a plaque or thrombus is replaced by an "artificial vessel" that takes over the conduction of blood flow. These operations are almost always performed on a non-working heart with cardiopulmonary bypass, after bypass surgery, the patient has to recover from a major surgical injury for a long time. The bypass method has many contraindications, especially in patients with a weakened body, but if the operation is successful, the results are usually good.

Currently, endovascular surgery (X-ray surgery) is considered the most promising method of treating IHD. The term "endovascular" is translated as "inside the vessel." This relatively young branch of medicine has already won a strong position in the treatment of coronary artery disease. All interventions are performed without incisions, through punctures in the skin, under X-ray observation, local anesthesia is sufficient for the operation. All these features are most important for those patients for whom, due to concomitant diseases, or because of the general weakness of the body, traditional surgical intervention is contraindicated. Of the methods of endovascular surgery for IHD, balloon angioplasty and stenting are most often used, which allow restoring patency in arteries affected by ischemia. When using balloon angioplasty, a special balloon is inserted into the vessel, and then it swells up and “pushes” atherosclerotic plaques or blood clots to the sides. After that, a so-called stent is inserted into the artery - a mesh tubular frame made of "medical" stainless steel or alloys of biologically inert metals, capable of expanding independently and maintaining the shape given to the vessel.

Treatment of coronary heart disease primarily depends on the clinical form. For example, although some general principles of treatment are used for angina pectoris and myocardial infarction, nevertheless, the tactics of treatment, the selection of an activity regimen and specific drugs can be fundamentally different. However, there are some general areas that are important for all forms of coronary artery disease.

1. Limitation physical loads. During physical activity, the load on the myocardium increases, and as a result, the demand of the myocardium for oxygen and nutrients increases. If the blood supply to the myocardium is disturbed, this need is unsatisfied, which actually leads to manifestations of coronary artery disease. Therefore, the most important component of the treatment of any form of coronary artery disease is the limitation of physical activity and its gradual increase during rehabilitation.

2. Diet. With IHD, in order to reduce the load on the myocardium in the diet, the intake of water and sodium chloride (salt) is limited. In addition, given the importance of atherosclerosis in the pathogenesis of coronary artery disease, much attention is paid to limiting foods that contribute to the progression of atherosclerosis. An important component of the treatment of coronary artery disease is the fight against obesity as a risk factor.

The following food groups should be limited, or if possible, avoided.

Animal fats (lard, butter, fatty meats)

· Fried and smoked food.

Products containing a large amount of salt (salted cabbage, salted fish, etc.)

Limit intake of high-calorie foods, especially fast-absorbing carbohydrates. (chocolate, sweets, cakes, pastry).

To correct body weight, it is especially important to monitor the ratio of energy coming from the food eaten, and energy consumption as a result of the body's activities. For stable weight loss, the deficit should be at least 300 kilocalories daily. On average, a person who is not engaged in physical work spends 2000-2500 kilocalories per day.

3. Pharmacotherapy at ischemic heart disease. There are a number of groups of drugs that can be indicated for use in one form or another of coronary artery disease. In the US, there is a formula for the treatment of coronary artery disease: "A-B-C". It involves the use of a triad of drugs, namely antiplatelet agents, β-blockers and hypocholesterolemic drugs.

Also, in the presence of concomitant hypertension, it is necessary to ensure the achievement of target levels of blood pressure.

Antiplatelet agents (A). Antiplatelet agents prevent the aggregation of platelets and erythrocytes, reduce their ability to stick together and adhere to the vascular endothelium. Antiplatelet agents facilitate the deformation of erythrocytes when passing through the capillaries, improve blood flow.

Aspirin - taken once a day at a dose of 100 mg, if myocardial infarction is suspected, a single dose can reach 500 mg.

Clopidogrel - taken once a day, 1 tablet 75 mg. Mandatory admission within 9 months after endovascular interventions and CABG.

β-blockers (B). Due to the action on β-arenoreceptors, blockers reduce heart rate and, as a result, myocardial oxygen consumption. Independent randomized trials confirm an increase in life expectancy when taking β-blockers and a decrease in the frequency of cardiovascular events, including repeated ones. At present, it is not advisable to use the drug atenolol, since, according to randomized trials, it does not improve the prognosis. β-blockers are contraindicated in concomitant pulmonary pathology, bronchial asthma, COPD. The following are the most popular β-blockers with proven prognostic properties in coronary artery disease.

Metoprolol (Betaloc Zok, Betaloc, Egiloc, Metocard, Vasocardin);

bisoprolol (Concor, Coronal, Bisogamma, Biprol);

Carvedilol (Dilatrend, Talliton, Coriol).

- Statins and Fibrates (C). Cholesterol-lowering drugs are used to reduce the rate of development of existing atherosclerotic plaques and prevent the occurrence of new ones. These drugs have been proven to have a positive effect on life expectancy, and these drugs reduce the frequency and severity of cardiovascular events. The target cholesterol level in patients with coronary heart disease should be lower than in those without coronary artery disease, and equal to 4.5 mmol/l. The target level of LDL in patients with IHD is 2.5 mmol/l.

lovastatin;

simvastatin;

atorvastatin;

Rosuvastatin (the only drug that significantly reduces the size of atherosclerotic plaque);

fibrates. They belong to a class of drugs that increase the anti-atherogenic fraction of HDL, with a decrease in which increases mortality from coronary artery disease. They are used to treat dyslipidemia IIa, IIb, III, IV, V. They differ from statins in that they mainly reduce triglycerides (VLDL) and can increase the HDL fraction. Statins predominantly lower LDL and do not significantly affect VLDL and HDL. Therefore, for the most effective treatment of macrovascular complications, a combination of statins and fibrates is required. With the use of fenofibrate, mortality from coronary artery disease is reduced by 25%. Of the fibrates, only fenofibrate is safely combined with any class of statin (FDA).

fenofibrate

Other classes: omega-3 polyunsaturated fatty acids (Omacor). In IHD, they are used to restore the phospholipid layer of the cardiomyocyte membrane. By restoring the structure of the cardiomyocyte membrane, Omacor restores the basic (vital) functions of the heart cells - conductivity and contractility, which were impaired as a result of myocardial ischemia.

Nitrates. There are nitrates for injection.

The drugs in this group are derivatives of glycerol, triglycerides, diglycerides and monoglycerides. The mechanism of action is the influence of the nitro group (NO) on the contractile activity of vascular smooth muscles. Nitrates mainly act on the venous wall, reducing the preload on the myocardium (by expanding the vessels of the venous bed and depositing blood). A side effect of nitrates is a decrease in blood pressure and headaches. Nitrates are not recommended for use with blood pressure below 100/60 mm Hg. Art. In addition, it is now reliably known that nitrate intake does not improve the prognosis of patients with coronary artery disease, that is, it does not lead to an increase in survival, and is currently used as a drug to relieve symptoms of angina pectoris. Intravenous drip of nitroglycerin allows you to effectively deal with the symptoms of angina pectoris, mainly against the background of high blood pressure.

Nitrates exist in both injectable and tablet forms.

nitroglycerin;

isosorbide mononitrate.

Anticoagulants. Anticoagulants inhibit the appearance of fibrin threads, they prevent the formation of blood clots, help stop the growth of already existing blood clots, increase the effect of endogenous enzymes that destroy fibrin on blood clots.

Heparin (the mechanism of action is due to its ability to specifically bind to antithrombin III, which dramatically increases the inhibitory effect of the latter in relation to thrombin. As a result, blood coagulates more slowly).

Heparin is injected under the skin of the abdomen or using an intravenous infusion pump. Myocardial infarction is an indication for the appointment of heparin thromboprophylaxis, heparin is prescribed at a dose of 12500 IU, injected under the skin of the abdomen daily for 5-7 days. In the ICU, heparin is administered to the patient using an infusion pump. The instrumental criterion for prescribing heparin is the presence of S-T segment depression on the ECG, which indicates an acute process. This symptom is important in terms of differential diagnosis, for example, in cases where the patient has ECG signs of previous heart attacks.

Diuretics. Diuretics are designed to reduce the load on the myocardium by reducing the volume of circulating blood due to the accelerated removal of fluid from the body.

Loopback. The drug "Furosemide" in tablet form.

Loop diuretics reduce the reabsorption of Na + , K + , Cl - in the thick ascending part of the loop of Henle, thereby reducing the reabsorption (reabsorption) of water. They have a fairly pronounced fast action, as a rule, they are used as emergency drugs (for forced diuresis).

The most common drug in this group is furosemide (Lasix). Exists in injection and tablet forms.

Thiazide. Thiazide diuretics are Ca 2+ sparing diuretics. By reducing the reabsorption of Na + and Cl - in the thick segment of the ascending loop of Henle and the initial section of the distal nephron tubule, thiazide drugs reduce urine reabsorption. With the systematic use of drugs of this group, the risk of cardiovascular complications in the presence of concomitant hypertension is reduced.

hypothiazide;

indapamide.

Inhibitorsangiotensin-convertingenzyme. By acting on the angiotensin-converting enzyme (ACE), this group of drugs blocks the formation of angiotensin II from angiotensin I, thus preventing the effects of angiotensin II, that is, leveling vasospasm. This ensures that the target blood pressure figures are maintained. The drugs of this group have a nephro- and cardioprotective effect.

enalapril;

lisinopril;

captopril.

Antiarrhythmicdrugs. The drug "Amiodarone" is available in tablet form.

Amiodarone belongs to the III group of antiarrhythmic drugs, has a complex antiarrhythmic effect. This drug acts on Na + and K + channels of cardiomyocytes, and also blocks b- and b-adrenergic receptors. Thus, amiodarone has antianginal and antiarrhythmic effects. According to randomized clinical trials, the drug increases the life expectancy of patients who regularly take it. When taking tablet forms of amiodarone, the clinical effect is observed after approximately 2-3 days. The maximum effect is achieved after 8-12 weeks. This is due to the long half-life of the drug (2-3 months). In this regard, this drug is used in the prevention of arrhythmias and is not a means of emergency care.

Taking into account these properties of the drug, the following scheme of its use is recommended. During the saturation period (the first 7-15 days), amiodarone is prescribed at a daily dose of 10 mg/kg of the patient's weight in 2-3 doses. With the onset of a persistent antiarrhythmic effect, confirmed by the results of daily ECG monitoring, the dose is gradually reduced by 200 mg every 5 days until a maintenance dose of 200 mg per day is reached.

Othergroupsdrugs.

Ethylmethylhydroxypyridine

The drug "Mexidol" in tablet form. Metabolic cytoprotector, antioxidant-antihypoxant, which has a complex effect on the key links in the pathogenesis of cardiovascular disease: anti-atherosclerotic, anti-ischemic, membrane-protective. Theoretically, ethylmethylhydroxypyridine succinate has a significant positive effect, but at present, there are no data on its clinical effectiveness based on independent randomized placebo-controlled trials.

· Mexicor;

The coronator

trimetazidine.

4. Usage antibiotics at ischemic heart disease. There are clinical observations of the comparative efficacy of two different courses of antibiotics and placebo in patients admitted to the hospital with either acute myocardial infarction or unstable angina. Studies have shown the effectiveness of a number of antibiotics in the treatment of coronary artery disease. The effectiveness of this type of therapy is not pathogenetically substantiated, and this technique is not included in the standards for the treatment of coronary artery disease.

5. Endovascular coronary angioplasty. The use of endovascular (transluminal, transluminal) interventions (coronary angioplasty) in various forms of coronary artery disease is being developed. These interventions include balloon angioplasty and coronary angiography-guided stenting. In this case, the instruments are inserted through one of the large arteries (in most cases, the femoral artery is used), and the procedure is performed under the control of fluoroscopy. In many cases, such interventions help prevent the development or progression of myocardial infarction and avoid open surgery.

This direction of treatment of coronary artery disease is engaged in a separate area of ​​cardiology - interventional cardiology.

6. Surgical treatment.

Coronary artery bypass grafting is performed.

With certain parameters of coronary heart disease, there are indications for coronary bypass surgery - an operation in which the blood supply to the myocardium is improved by connecting the coronary vessels below the site of their lesion with external vessels. The best known is coronary artery bypass grafting (CABG), in which the aorta is connected to segments of the coronary arteries. For this, autografts (usually the great saphenous vein) are often used as shunts.

It is also possible to use balloon dilatation of blood vessels. In this operation, the manipulator is introduced into the coronary vessels through a puncture of the artery (usually the femoral or radial), and the vessel lumen is expanded by means of a balloon filled with a contrast agent, the operation is, in fact, coronary vessel bougienage. Currently, “pure” balloon angioplasty without subsequent stent implantation is practically not used, due to low efficiency in the long-term period.

7. Other non-drug methods treatment

- Hirudotherapy. Hirudotherapy is a method of treatment based on the use of antiplatelet properties of leeches saliva. This method is an alternative and has not been clinically tested for compliance with the requirements of evidence-based medicine. Currently, it is used relatively rarely in Russia, it is not included in the standards of medical care for coronary artery disease, it is used, as a rule, at the request of patients. The potential positive effects of this method are the prevention of thrombosis. It should be noted that when treated according to approved standards, this task is performed using heparin prophylaxis.

- Methodshock wavetherapy. The impact of shock waves of low power leads to myocardial revascularization.

An extracorporeal source of a focused acoustic wave allows you to influence the heart remotely, causing "therapeutic angiogenesis" (vascular formation) in the area of ​​myocardial ischemia. Exposure to UVT has a double effect - short-term and long-term. First, the vessels dilate, and blood flow improves. But the most important thing begins later - new vessels appear in the affected area, which provide a long-term improvement.

Low-intensity shock waves induce shear stress in the vascular wall. This stimulates the release of vascular growth factors, starting the process of growth of new vessels that feed the heart, improving myocardial microcirculation and reducing the effects of angina pectoris. The theoretical results of such treatment are a decrease in the functional class of angina pectoris, an increase in exercise tolerance, a decrease in the frequency of attacks and the need for drugs.

However, it should be noted that at present there have been no adequate independent multicenter randomized studies evaluating the effectiveness of this technique. Studies cited as evidence of the effectiveness of this technique are usually produced by the manufacturing companies themselves. Or do not meet the criteria of evidence-based medicine.

This method has not been widely used in Russia due to questionable efficiency, high cost of equipment, and lack of relevant specialists. In 2008, this method was not included in the standard of medical care for coronary artery disease, and these manipulations were performed on a contractual commercial basis, or in some cases under voluntary medical insurance contracts.

- Usagestemcells. When using stem cells, those performing the procedure expect that the pluripotent stem cells introduced into the patient's body will differentiate into the missing cells of the myocardium or vascular adventitia. It should be noted that stem cells actually have this ability, but at present the level of modern technologies does not allow us to differentiate a pluripotent cell into the tissue we need. The cell itself makes the choice of the path of differentiation - and often not the one that is needed for the treatment of coronary artery disease.

This method of treatment is promising, but has not yet been clinically tested and does not meet the criteria of evidence-based medicine. Years of scientific research are required to provide the effect that patients expect from the introduction of pluripotent stem cells.

Currently, this method of treatment is not used in official medicine and is not included in the standard of care for coronary artery disease.

- quantumtherapyischemic heart disease. It is a therapy by exposure to laser radiation. The effectiveness of this method has not been proven, an independent clinical study has not been conducted.

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term paper, added 04/21/2015


Classification of ischemic heart disease. Basic organic nitrates and groups of antianginal agents. Pharmacodynamics of nitrates and their effect on coronary circulation. Development of tolerance (addiction) to nitrates, methods of prevention.

presentation, added 10/21/2013


Influence of risk factors on the development of coronary heart disease, its forms (angina pectoris, myocardial infarction) and complications. Atherosclerosis as the main cause of coronary heart disease. Diagnosis and principles of medical correction of disorders.

test, added 02/22/2010


The concept of coronary heart disease, its types, symptoms, treatment and prevention. Causes of impaired blood flow in the coronary arteries. Morbidity and mortality from cardiovascular diseases in Russia. Factors affecting predisposition.

term paper, added 04/07/2015


Symptoms of coronary heart disease (CHD). Traditional instrumental methods diagnosis of coronary artery disease. Electrocardiography (ECG) at rest, 24-hour Holter ECG monitoring. Diagnostic possibilities of echocardiography. Stress tests, coronary angiography.