Clinical guidelines for angina pectoris. Recommendations of the European Society of Cardiology for the management of patients with stable coronary heart disease. Statins for the treatment of angina pectoris

Lupanov V.P.

In December 2012 G. published in the Journal of the American College of Cardiology new practical recommendations on diagnostics and treatment sick stable ischemic disease hearts(CHS).

To the editorial committee for the preparation recommendations entered: American College of Cardiology (ACCF), American association hearts(A.H.A.) American College of Physicians (ACP), American Association for Thoracic Surgery (AATS), Preventive Nurses Association (PCNA), Society for Cardiovascular Angiography and Interventional Interventions (SCAI), Society for Thoracic Surgeons (STS). Recommendations contain 120 pages, 6 chapters. 4 appendices, bibliography - 1266 sources.

AT chapter 4 of these recommendations issues considered medical treatment stable ischemic heart disease. This article only deals with questions medical treatment stable ischemic heart disease.

Recommendations on treatment stable IHD should help practitioners make the right decisions in various clinical situations. To do this, it is important to navigate the class of recommendations (I, II, III) and levels of evidence (A, B, C) of each of the recommended interventions (Table 1).

Patients with stable IBS should be carried out treatment according to the recommendations (guidelines) directed medical therapy - guideline-directed medical therapy (GDMT) (a new term meaning optimal medical therapy as defined by ACCF/AHA; First of all, this applies to class I recommendations).

Diet, weight loss and regular physical activity;

If the patient is a smoker - stop smoking;

Reception of acetylsalicylic acid (ASA) 75-162 mg daily;

Taking statins in moderate doses;

If the patient hypertensive- antihypertensive therapy until BP is reached<140/90 мм рт.ст.;

If the patient is diabetic - proper control glycemia .

Traditional modifiable risk factors for CHD - smoking, hypertension, dyslipidemia, diabetes mellitus and obesity - are observed in the majority of patients and are associated with high coronary risk. Therefore, the impact on the main risk factors: diet control, exercise, treatment diabetes, hypertension and dyslipidemia (4.4.1.1), smoking cessation and weight loss should be part of the overall strategy treatment all patients stable ischemic heart disease.

4.4.1. Modification of risk factors

4.4.1.1. Effect on blood lipids

1. Lifestyle modification, including daily physical activity, is highly recommended for all patients with stable IHD (level of evidence B).

2. Dietary therapy for all patients should include reduction of saturated fat intake (<7% от общей калорийности), трансжирных кислот (<1% от общей калорийности) и общего холестерина (<200 мг/дл) (уровень доказательности В).

3. In addition to therapeutic lifestyle changes, moderate or high doses of statins should be prescribed in the absence of contraindications and documented side effects (Evidence A).

1. For patients who cannot tolerate statins, lowering low-density lipoprotein cholesterol with bile acid sequestrants (FFAs)*, niacin**, or a combination of both is reasonable (Evidence B).

Here is a summary American clinical guidelines consisting of medical therapy to prevent myocardial infarction and death (4.4.2); and therapy to relieve syndromes (4.4.3).

additional drug therapy to prevent

myocardial infarction and death

in patients stable ischemic heart disease

4.4.2.1. Antiplatelet therapy

1. Treatment ASA at a dose of 75-162 mg daily should be continued indefinitely in the absence of contraindications in patients with stable IHD (level of evidence A).

2. Treatment clopidogrel is reasonable in cases where ASA is contraindicated in patients with stable IHD (level of evidence B).

1. Treatment ASA at doses of 75 to 162 mg daily and clopidogrel 75 mg daily. may be reasonable in some patients with stable high-risk CAD (Evidence B).

4.4.2.2. Therapy with b-blockers

1. Beta-blocker therapy should be started and continued for 3 years in all patients with normal left ventricular function after myocardial infarction or acute coronary syndrome (Evidence B).

2. β-blockers should be used in all patients with left ventricular systolic dysfunction (EF≤40%), heart failure, or prior to myocardial infarction, unless contraindicated (carvedilol, metoprolol succinate, or bisoprolol are recommended and have been shown to reduce the risk of death (level of evidence A).

1. β-blockers may be considered as chronic therapy for all other patients with CAD or other vascular disease (Evidence C).

4.4.2.3. ACE inhibitors and blockers

angiotensin receptors

(renin-angiotensin-aldosterone blockers)

1. ACE inhibitors should be given to all patients with stable CAD who also have hypertension, diabetes mellitus, a left ventricular EF of 40% or less, or chronic kidney disease, unless contraindicated (Evidence A).

2. Angiotensin receptor blockers are recommended for patients with stable CAD who have hypertension, diabetes mellitus, left ventricular systolic dysfunction, or chronic kidney disease and are indications for ACE inhibitors but cannot tolerate them (Evidence A).

1. Treatment with an ACE inhibitor is reasonable in patients with both stable CAD and other vascular disease (Evidence B).

2. Angiotensin receptor blockers should also be used in other patients who cannot tolerate ACE inhibitors (Evidence level C).

4.4.2.4. Influenza vaccination

4.4.2.5. Additional therapy to reduce the risk of myocardial infarction and death

Class III. Benefit not proven.

3. Treatment of elevated homocysteine ​​with folic acid, vitamins B6 and B12 to reduce CV risk or improve clinical outcomes in patients with stable CAD is not recommended (Evidence A).

4. Chelation therapy (intravenous EDTA - ethylene diamine tetraacetic acid) to improve symptoms or reduce cardiovascular risk in patients with stable CAD is not recommended (level of evidence C).

5. Treatment with garlic, coenzyme Q10, selenium and chromium to reduce CV risk or improve clinical outcomes in patients with stable CAD is not recommended (Evidence C).

4.4.3. Medical therapy

to relieve symptoms

4.4.3.1. Therapy with anti-ischemic

drugs

1. β-blockers should be given as initial therapy for symptomatic relief in patients with stable CAD (Evidence B).

2. Calcium channel blockers or long-acting nitrates should be given for symptomatic relief when β-blockers are contraindicated or cause unacceptable side effects in patients with stable CAD (Evidence B).

3. Calcium channel blockers or long-acting nitrates in combination with β-blockers should be given to relieve symptoms when initial β-blocker therapy fails in patients with stable CAD (Evidence B).

4. Sublingual nitroglycerin or nitroglycerin spray is recommended for immediate relief of angina in patients with stable CAD (Evidence B).

1. Treatment with a long-acting non-dihydropyridine calcium channel blocker (verapamil or diltiazem) is reasonable for symptom relief when β-blockers are not effective as initial therapy in patients with stable CAD (Evidence B).

2. Ranolazine treatment may be useful when given as a substitute for a β-blocker to relieve symptoms in patients with stable CAD, if initial β-blocker treatment results in unacceptable side effects or is ineffective, or initial β-blocker treatment is contraindicated ( level of evidence B).

3. Treatment with ranolazine in combination with a β-blocker in patients with stable CAD may be useful in relieving symptoms when initial β-blocker monotherapy fails (Evidence A).

Consider antianginal drugs that are used or not approved for use in the US in new American guidelines for the treatment of stable coronary artery disease 2012 d. Different Levels of Evidence of Effectiveness new pharmacological agents in general are very different, drugs are not without side effects, especially in elderly patients and when combined with other drugs.

4.4.3.1.4. Ranolazine is a partial inhibitor of fatty acid oxidation, which has antianginal properties. It is a selective inhibitor of late sodium channels, which prevent intracellular calcium overload, a negative factor in myocardial ischemia. Ranolazine reduces contractility, stiffness of the myocardial wall, has an anti-ischemic effect and improves myocardial perfusion without changing heart rate and blood pressure. The antianginal efficacy of ranolazine has been shown in three studies in IHD patients with stable angina (MARISA, CARISA, ERICA). The drug is a metabolic drug that reduces myocardial oxygen demand, it is indicated for use in combination with traditional antianginal therapy in those patients who remain symptomatic when taking traditional drugs. Compared with placebo, ranolazine reduced the frequency of angina attacks and increased exercise tolerance in a large study in patients with angina who had experienced acute coronary syndrome (MERLIN-TIMI) .

Since 2006, ranolazine has been used in the USA and in most European countries. When taking the drug, there may be a prolongation of the QT interval on the ECG (approximately 6 milliseconds at the maximum recommended dose), although this is not considered responsible for the phenomenon of torsades de pointes, especially in patients who experience dizziness. Ranolazine also reduces glycated hemoglobin (HbA1c) in patients with diabetes mellitus, but the mechanism and consequences of this have not yet been established. Combination therapy with ranolazine (1000 mg 2 times / day) with simvastatin increases the plasma concentration of simvastatin and its active metabolite by 2 times. Ranolazine is well tolerated, side effects - constipation, nausea, dizziness and headache - are rare. The frequency of syncope when taking ranolazine is less than 1%.

4.4.3.1.5.1. Nicorandil. The nicorandil molecule contains a nitrate group and a residue of nicotinic acid amide, therefore it has the properties of organic nitrates and activators of adenosine triphosphate-dependent potassium channels. The drug balances pre- and afterload on the myocardium. By opening ATP-dependent potassium channels, nicorandil fully reproduces the effect ischemic preconditioning: promotes energy conservation in the heart muscle and prevents the necessary cellular changes in conditions of ischemia. It has also been proven that nicorandil reduces platelet aggregation, stabilizes coronary plaque, normalizes endothelial function and sympathetic nervous activity in heart. Nicorandil does not cause the development of tolerance, does not affect heart rate and blood pressure, conduction and contractility of the myocardium, lipid metabolism and glucose metabolism. Nicorandil is recommended for use in the European guidelines (2006) and the recommendations of the VNOK (2008) as monotherapy for intolerance or contraindications to β-blockers or calcium antagonists, or as an additional drug for their insufficient effectiveness.

The antianginal activity of nicorandil has been demonstrated in many studies. Its prognostic benefit has been shown in comparison with placebo in patients with coronary artery disease. disease hearts in the IONA study. In this study (n=5126, follow-up 12–36 months), significant benefits in the treatment group (20 mg twice daily) were found across several composite measures, including the primary endpoint (CHD death, non-fatal MI or unplanned hospitalization for CAD: hazard ratio 0.83, 95% confidence interval 0.72-0.97; p = 0.014). This positive result was mainly due to a decrease in acute coronary events. Interestingly, in this study, treatment with nicorandil was not associated with a reduction in symptoms as assessed by the Canadian classification.

The main side effect of nicorandil is headache at the beginning of treatment (discontinuation rate 3.5-9.5%), which can be avoided by gradually increasing the dose to the optimal level. Perhaps the development of allergic reactions, skin rash, itching, gastrointestinal symptoms. Occasionally, undesirable effects such as dizziness, malaise and fatigue develop. Ulceration was first described in the oral cavity (aphthous stomatitis) and was rare. However, in subsequent studies, a few cases of perianal, colonic, vulvovaginal, and groin ulceration have been described, which can be very serious, although always reversible upon discontinuation of treatment. Nicorandil is included in the first Russian National Guidelines for Cardiovascular Prevention: recommendation class I, level of evidence B.

4.4.3.1.5.2. Ivabradin. New a class of antianginal drugs - inhibitors of the activity of sinus node cells (ivabradine) - has a pronounced selective ability to block If-ion channels, which are responsible for the sinoatrial pacemaker and cause a slowdown in heart rate. Currently, ivabradine is the only pulse-slowing drug used in the clinic, which realizes its effects at the level of the pacemaker cells of the sinoatrial node, i.e. is a true blocker of If-currents. Ivabradine can be used in patients with stable angina pectoris with sinus rhythm, both in case of intolerance or contraindications to the use of β-blockers, and for combined use with β-blockers, if the latter do not control heart rate (more than 70 beats / min.), And increasing their dose is impossible . In chronic stable angina, the drug at a dose of 5-10 mg / day. lowers heart rate and myocardial oxygen demand without negative inotropic action. Further trials of the drug are ongoing, including in patients with refractory angina and chronic heart failure. One of the side effects of ivabradine is the induction of phosphene disturbances in light perception (luminous dots, various figures that appear in the dark) associated with changes in the retina. The frequency of eye symptoms is about 1%, they disappear on their own (in the first 2 months of treatment in 77% of patients) or when you stop taking ivabradine. Possible excessive bradycardia (frequency of occurrence - 2% at the recommended dose of 7.5 mg 2 times / day.). In this way, new Pharmacological drugs - ivabradine, nicorandil, ranolazine - may be effective in some patients with angina pectoris, but additional clinical trials are needed.

4.4.3.1.5.3. Trimetazidine. The anti-ischemic effect of trimetazidine is based on its ability to increase the synthesis of adenosine triphosphoric acid in cardiomyocytes with insufficient oxygen supply due to a partial switch in myocardial metabolism from fatty acid oxidation to a less oxygen-consuming pathway - glucose oxidation. This increases the coronary reserve, although the antianginal effect of trimetazidine is not due to a decrease in heart rate, a decrease in myocardial contractility, or vasodilation. Trimetazidine is able to reduce myocardial ischemia in the early stages of its development (at the level of metabolic disorders) and thereby prevent the occurrence of its later manifestations - anginal pain, rhythm disturbances hearts. decrease in myocardial contractility.

A meta-analysis by the Cochrane Collaboration grouped trials of trimetazidine versus placebo or other antianginal drugs in patients with stable angina. The analysis showed that, compared with placebo, trimetazidine significantly reduced the frequency of weekly angina attacks, nitrate intake, and the time to onset of severe ST segment depression during exercise tests. The antianginal and anti-ischemic efficacy of trimetazidine taken in combination with β-blockers is superior to that of long-acting nitrates and calcium antagonists. The severity of the positive effect of trimetazidine increases as the duration of treatment increases. Additional benefits of drug therapy may be obtained in patients with left ventricular systolic dysfunction. ischemic nature, including after acute myocardial infarction. The use of trimetazidine before surgical interventions on the coronary arteries (PCI, CABG) can reduce the severity of myocardial damage during their implementation. Long-term treatment with trimetazidine after surgery reduces the likelihood of recurrence of angina attacks and the frequency of hospitalizations for acute coronary syndrome, reduces the severity of ischemia, improves exercise tolerance and quality of life. The results of clinical studies and their meta-analyses confirm the good tolerability of trimetazidine therapy, which is superior to that of hemodynamically active ananginal drugs. Trimetazidine can be used either as an addition to standard therapy or as a substitute for it if it is not well tolerated. The drug is not used in the United States, but is widely used in Europe, Russia and more than 80 countries around the world.

Conclusion

Stable angina pectoris (taking into account persons who have previously had a myocardial infarction) is one of the most common forms of coronary artery disease. It is estimated that the number of people suffering from angina pectoris is 30-40 thousand per 1 million population. In the United States, more than 13 million patients with coronary disease hearts. of these, about 9 million have angina pectoris.

The main goals of treating angina pectoris are to relieve pain and prevent the progression of the disease by reducing cardiovascular complications.

The American guidelines define treatment success. The primary goals of treating patients with stable CAD are to minimize the chance of death while maintaining good health and function. hearts. The most specific goals are: reduction of premature cardiac death; prevention of complications of stable coronary artery disease, which directly or indirectly lead to a deterioration in functional ability, including non-fatal myocardial infarction and heart failure; maintaining or restoring a level of activity, functional ability and quality of life that satisfies the patient; complete or almost complete elimination of symptoms of ischemia; minimizing the cost of maintaining health, reducing the frequency of hospitalizations and conducting repeated (often unreasonable) functional methods of research and treatment, reducing the side effects of excessive prescriptions of drugs and examination methods.

Doctors are accustomed to conducting symptomatic therapy aimed at relieving angina attacks, reducing shortness of breath or swelling, lowering blood pressure or heart rate to normal levels. However, strategic thinking is also necessary at the bedside: one should think about the long-term prognosis, assess the risk of possible death and severe complications. disease. try to achieve the target levels of the main indicators of blood lipids, biochemical parameters and markers of inflammation, normalization of body weight of patients, etc. .

As shown in the new American guidelines, strategic therapy with statins, ASA, and, when indicated, taking β-blockers, ACE inhibitors, or angiotensin II receptor antagonists, just provides a real and reliable opportunity to reduce mortality and improve the course of coronary artery disease. Patients should definitely know that the ultimate goal of using these drugs is to prevent premature death and radically improve the course of disease and prognosis, and for this it is necessary to use these drugs for a long time (at least for 3-5 years). Individual therapy of patients at high risk (which includes patients with angina pectoris) differs from the general population by increasing efforts to prevent risk factors (from the appearance to reduction of their severity).

In recent years, along with traditional classes of drugs, such as nitrates (and their derivatives), β-blockers, calcium channel blockers, other drugs with different mechanisms of action (trimetazidine, ivabradine, partly nicorandil), as well as a new a drug (ranolazine) recently approved in the United States that reduces myocardial ischemia and is a useful adjunct to treatment. The American recommendations also indicate those drugs (class III), the use of which does not alleviate the course of stable coronary artery disease and improve the prognosis of patients.

Literature

1.Fihn S.D. Cardin J.M. Abrams J. et al. 2012 ACCF/AHA/ACP/FCP/AATS/PCNA/SCAI/SNS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease // J. Am. Coll. cardiol. 2012 . Vol.60 No. 24. P. e44-e164.

2. Nash D.N. Nash S.D. Ranolazine for chronic stable angina // Lancet. 2008 Vol. 372. P. 1335-1341.

3. Stone P.Y. The Anti-Ischemic Mechanism of Action of Ranolazine in Stable Ischemic Heart Disease // JACC. 2010 Vol. 56(12). P. 934-942.

4. Lupanov V.P. Ranolazine at ischemic disease hearts// Rational pharmacotherapy in cardiology. - 2012 . - T. 8, No. 1. - S. 103-109.

5. Wilson S.R. Scirica B.M. Braunwald E. et al. Efficacy of ranolazine in patients with chronic angina observations from the randomized, double-blind, placebo-controlled MERLIN-TIMI (Metabolic Efficiency With Ranolazine for Less Ischemia in Non-ST-Segment Elevation Acute Coronary Syndromes) 36 Trial // J. Am. Coll. cardiol. 2009 Vol. 53(17). P. 1510-1516.

6. Di Monaco. Sestito A. The patient with chronic ischemic heart disease. Role of ranolazine in management of stable angina // Eur. Rev. Med. Pharmacol. sci. 2012. Vol. 16(12). P. 1611-1636.

7 Timmis A.D. Chaitman B.R. Crager M. Effects of ranolazine on exercise tolerance and HbA1c in patients with angina and diabetes // Eur. Heart J. 2006. Vol. 27. P. 42-48.

8. Gayet J-L. Paganelli F. Conen-Solal A.F. Update on the medical treatment of stable angina // Arch. Cardiovasc. Dis. 2011 Vol. 104. P. 536-554.

9. Horinaka S. Use of Nicorandil in cardiovascular disease and its optimization // Drugs. 2011 Vol. 71, no. 9. P. 1105-1119.

10. Lupanov V.P. Maksimenko A.V. Protective ischemia in cardiology. Forms of myocardial conditioning (review) // Cardiovasc. therapy and prevention. - 2011. - No. 10(1). - S. 96-103.

11. Lupanov V.P. The use of nicorandil, an activator of potassium channels, in the treatment of patients with ischemic disease hearts// Handbook of the polyclinic doctor. - 2011. - No. 8. - S. 44-48.

12. IONA Study Group. Effect of nicorandil on coronary events in patients with stable angina: the Impact Of Nicorandil in Angina (IONA) randomised trial // Lancet. 2002 Vol. 359. P. 1269-1275.

13. Cardiovascular prevention. National recommendations of VNOK // Cardiovasc. therapy and prevention. - 2011. - No. 10(6); App.2. - S. 57.

14. Tendera M. Borer J.S. Tardif J.C. Efficacy of I(f) inhibition with ivabradine in different subpopulations with stable angina pectoris // Cardiol. 2009 Vol. 114(2). P. 116-125.

15. Aronov D.M. Arutyunov G.P. Belenkov Yu.N. Agreed opinion of experts on the advisability of using the myocardial cytoprotector trimetazidine (Preductal MV) in the complex therapy of patients with chronic forms ischemic disease hearts// Cardiosomatics. - 2012. - T. 3, No. 2. - C. 58-60.

16. Lupanov V.P. Trimetazidine MB in patients with ischemic disease heart (review) // Consilium Med. - 2010. - T. 12, No. 1. - C. 5-11.

17. Ciapponi A. Pizarro R. Harrison J. Trimetazidine for stable angina // Cochrane Database Syst. Rev. 2005: CD003614.

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National guidelines for the prevention, diagnosis and treatment of arterial hypertension

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The recommendations were developed by experts of the All-Russian Scientific Society of Cardiology in 2001 and approved at the Russian National Congress of Cardiology on October 11, 2001. The second revision of the Recommendations was carried out in 2004.

Committee of experts for the development of recommendations for the diagnosis and treatment of arterial hypertension: Belousov Yu.B. (Moscow), Borovkov N.N. (Nizhny Novgorod), Boytsov S.A. (Moscow), Britov A.N. (Moscow), Volkova E.G. (Chelyabinsk), Galyavich A.S. (Kazan), Glezer M.G. (Moscow), Grinshtein Yu.I. (Krasnoyarsk), Zadionchenko V.S. (Moscow), Kalev O.F. (Chelyabinsk), Karpov R.S. (Tomsk), Karpov Yu.A. (Moscow), Kobalava Zh.D. (Moscow), Kukharchuk V.V. (Moscow), Lopatin Yu.M. (Volgograd), Makolkin V.I. (Moscow), Mareev V.Yu. (Moscow), Martynov A.I. (Moscow), Moiseev V.S. (Moscow), Nebieridze D.V. (Moscow), Nedogoda S.V. (Volgograd), Nikitin Yu.P. (Novosibirsk), Oganov R.G. (Moscow), Ostroumova O.D. (Moscow), Olbinskaya L.I. (Moscow), Oshchepkova E.V. (Moscow), Pozdnyakov Yu.M. (Zhukovsky), Storozhakov G.I. (Moscow), Khirmanov V.N. (St. Petersburg), Chazova I.E. (Moscow), Shalaev (Tyumen), Shalnova S.A. (Moscow), Shestakova M.V. (Ryazan), Shlyakhto E.V. (St. Petersburg), Yakushin S.S. (Ryazan).

Dear colleagues!

The second version of the national recommendations for the prevention, diagnosis and treatment of arterial hypertension, as well as the first one, is the result of the joint work of experts from all regions of Russia. These guidelines have been compiled taking into account new data that have appeared since the publication of the first version in 2001. Based mainly on the results of large-scale international studies, they reflect current issues in the classification of arterial hypertension, the formulation of the diagnosis, as well as the algorithms of medical tactics. The recommendations are a concise and clear summary of current approaches to the prevention, diagnosis and treatment of arterial hypertension; they are intended primarily for use in practical public health. The All-Russian Scientific Society of Cardiology hopes that the introduction of improved recommendations will effectively change the state of the problem of diagnosing and treating arterial hypertension in Russia for the better.

President of the All-Russian Scientific Society of Cardiology,

Academician of RAMS

R. G. Oganov

Introduction

Since the publication of the first Russian recommendations in 2001 on the prevention, diagnosis and treatment of hypertension, new data have accumulated that require a revision of the recommendations. In this regard, at the initiative of the section of arterial hypertension of the VNOK and with the support of the Presidium of the VNOK, the second revision of the National Guidelines for the Prevention, Diagnosis and Treatment of Arterial Hypertension was developed and discussed. Well-known Russian specialists took part in them. At the congress of cardiologists in Tomsk, the second revision of the recommendations was officially approved.

Arterial hypertension (arterial hypertension) in the Russian Federation, as in all countries with developed economies, is one of the urgent medical and social problems. This is due to the high risk of complications, high prevalence and insufficient control in the population scale. In Western countries, blood pressure is properly controlled in less than 30% of the population, and in Russia in 17.5% of women and 5.7% of men with hypertension. The benefits of lowering blood pressure have been proven not only in a number of large, multicenter studies, but also in a real increase in life expectancy in Western Europe and the USA.

The second version of the recommendations was based on the European guidelines for the control of hypertension (2003). A feature of the second version, like the previous one, is that, in accordance with the current provisions set out in the latest European guidelines, hypertension is considered as one of the elements of the individual cardiovascular risk stratification system. AH, due to its pathogenetic significance and the possibility of regulation, is one of the most important components of this system. Such an approach to understanding the essence and role of hypertension as a risk factor can actually reduce CVD and mortality in Russia.

List of abbreviations and conventions

A - angiotensin

AV block - atrioventricular block

AG - arterial hypertension

BP - blood pressure

AIR - agonists of I 1 -imidazoline receptors

AK - calcium antagonists

ACS - associated clinical conditions

ACTH - adrenocorticotropic hormone

AO - abdominal obesity

ARP - renin activity in blood plasma

BA - bronchial asthma

BAB - beta-blockers

ACE inhibitors - angiotensin-converting inhibitors

enzyme

IHD - ischemic heart disease

MI - myocardial infarction

IMM LV - mass index of the myocardium of the left ventricle

BMI - body mass index

TIA - transient ischemic attack

Ultrasound - ultrasonography

FA - physical activity

FK - functional class

FN - physical activity

RF - risk factors

COPD - chronic obstructive pulmonary disease

CNS - central nervous system

ECG - electrocardiogram

EchoCG - echocardiography

Definition

The term "arterial hypertension" refers to the syndrome of increased blood pressure in "hypertension" and "symptomatic arterial hypertension".

The term "hypertension" (AH), proposed by G.F. Lang in 1948, corresponds to the concept of "essential hypertension" used in other countries.

Hypertension is commonly understood as a chronic disease, the main manifestation of which is hypertension, not associated with the presence of pathological processes, in which the increase in blood pressure is due to known, in modern conditions, often eliminated causes (“symptomatic arterial hypertension”). Due to the fact that AH is a heterogeneous disease that has fairly distinct clinical and pathogenetic variants with significantly different mechanisms of development at the initial stages, the term "arterial hypertension" is often used in the scientific literature instead of the term "hypertension".

Diagnostics

Diagnosis and examination of patients with hypertension are carried out in strict sequence, in accordance with the following tasks:

- determination of stability and degree of increase in blood pressure;

- exclusion of symptomatic hypertension or identification of its form;

- assessment of overall cardiovascular risk;

• identification of other risk factors for CVD and clinical conditions that may affect the prognosis and effectiveness of treatment; determination of a particular risk group in a patient;

Diagnosis of hypertension and subsequent examination includes the following steps:

• repeated measurements of blood pressure;
• collection of anamnesis;
• physical examination;
• laboratory and instrumental research methods: simpler at the first stage and complex at the second stage of the examination.

  Rules for measuring blood pressure

  The accuracy of blood pressure measurement and, accordingly, the guarantee of the diagnosis of hypertension, the determination of its degree, depend on compliance with the rules for measuring blood pressure.

  The following conditions are important for measuring blood pressure:

  Updated European Society of Cardiology Guidelines (2013) for the management of coronary heart disease and cardiovascular disease in patients with diabetes mellitus

  Summary. Changes have been made to the standards for the diagnosis and treatment of patients with coronary heart disease

  Participants of the European Society of Cardiology Congress, held from 31 August to 4 September 2013 in Amsterdam, the Netherlands, had the opportunity to briefly review the updated Guidelines for the diagnosis and treatment of stable coronary artery disease (CHD), as well as for the management of patients with diabetes mellitus or prediabetes and concomitant cardiovascular pathology.

  Both documents were presented on September 1, 2013 during the meeting of the European Society of Cardiology and include the following information for European cardiologists:

  • in patients with stable coronary artery disease, the functional component of coronary vascular disease plays a more significant role than before for stenting compared with the severity of angiographic data;
  • the assessment of the pretest probability (PTP) of diagnosing coronary artery disease has been updated to include more modern indicators compared to the 34-year-old Diamond and Forrester Chest Pain Prediction Rule;
  • for elderly patients with diabetes mellitus and cardiovascular pathology, the criteria for glycemic control are somewhat weakened in favor of the quality of life of patients;
  • in patients with diabetes mellitus and CAD with multiple coronary artery disease, coronary artery bypass grafting is the treatment of choice, but if the patient prefers stenting, eluting stents should be placed.

  The recommendations raise the importance of PTT for the diagnosis of stable CAD, as a "new set of pre-test probability parameters" has been developed. As before, they are based on the data of Diamond and Forrester in 1979. However, compared with 1979, the incidence of coronary artery stenosis in patients with angina pectoris has decreased significantly. However, the new criteria for PTP still focus on characterization of anginal pain (typical angina versus atypical angina versus non-anginal retrosternal pain), age, and gender of the patient.

  For example, in a patient with suspected coronary artery disease, using the new criteria as presented in the presentation at the Congress, in PTT<15% следует искать другие причины и рассмотреть вероятность функциональной коронарной болезни. При средних значениях ПТВ (15%–85%) пациенту следует провести неинвазивное обследование. Если ПТВ высокая - >85%, establish the diagnosis of coronary artery disease. Patients with severe symptoms or "clinical presentation suggestive of high-risk coronary anatomy" should be treated according to the Guidelines.

  The recommendations also raise the importance of modern imaging technologies, especially cardiac magnetic resonance imaging and coronary computed tomography angiography (CTA), but with the need for a sober critical approach. According to the authors of the new Guidelines, they tried to create a moderately conservative document, but "not as conservative as the 2012 American Guidelines and not as progressive as the NICE (National Institute for Health and Clinical Excellence) recommendations" 2010".

  According to the Guidelines, coronary CTA should be considered in stable CAD as an alternative to imaging stress technologies in patients with moderate PTT values ​​for stable CAD with expected high quality imaging data. It should also be considered in patients with moderate PTT values ​​for stable CAD after inconclusive exercise electrocardiography or imaging stress testing, and in patients with contraindications to stress testing if obtaining a complete diagnostic picture with coronary CTA is expected.

  Members of the working group for the preparation of the Recommendations also focus on the presence of three "forbidding" recommendations (ІІІС): do not evaluate calcification in asymptomatic patients; do not perform coronary CTA in asymptomatic patients as a screening test; do not perform coronary CTA with a high probability of vascular calcification.

  Also noteworthy is the perhaps more aggressive provision, compared to the 2012 American guidelines, that every patient seeking medical attention for chest pain should have an echocardiogram at first contact at rest.

  The guidelines also state that microvascular angina and vasospasm are much more common causes of angina than previously thought. The problem, according to the authors, is that most practitioners believe that coronary artery disease and, in particular, angina pectoris, are conditions caused by stenosis of the coronary arteries. Which, of course, is true, but does not exhaust all possible causes of the development of the disease.

  The Congress also presented updated recommendations for the treatment of stable coronary artery disease.

  Many patients are referred to catheterization laboratories without any symptoms of ischemia. Cardiac catheterization, as a method available in these laboratories, is used to measure blood flow in the coronary arteries - the so-called fractional blood flow reserve. The method for determining hemodynamically appropriate coronary artery disease in the absence of evidence of ischemia is classified as Class I clinical practice guideline, Level A evidence. Intracoronary ultrasound or optical coherence tomography may be considered (Guideline Class II, evidence level B) to characterize vascular lesions. and improve the efficiency of stenting.

  The guidelines have also contributed to a very tense debate between surgeons and interventional cardiologists vying for patients referred for coronary revascularization. Clear specific recommendations are formulated, mostly based on the SYNTAX score, which categorizes patients according to the severity of coronary artery disease, due to the anatomy of the coronary lesion.

  For example, in patients with clinically significant stenosis of the main left coronary artery - involving only one vessel - percutaneous coronary intervention (PCI) should be performed for stem or median lesions, however, if vascular lesions are localized distal to the bifurcation, a consultation of experts on the subject choice of PCI or coronary artery bypass grafting as a treatment option. In multivascular lesions, the SYNTAX scale should be used, with values<32 необходимо консилиумное решение, при значениях >33, coronary bypass surgery should be performed.

  There are no significant changes in the Guidelines regarding the medical treatment of stable coronary artery disease, with the exception of the inclusion of three drugs that debuted as antianginal drugs: ranolazine, nicorandil and ivabradine - all as second-line drugs.

  New in the Guidelines for patients with diabetes mellitus with cardiovascular pathology or high cardiovascular risk are patient-centered approaches to therapy: less aggressive glycemic control in elderly patients and simplified diagnosis, which focuses on the determination of glycated hemoglobin or fasting blood glucose, with backup using a glucose tolerance test only in "cases of uncertainty".

  Attention is also focused on the advantages of coronary artery bypass grafting as a method of first choice when deciding whether to conduct revascularization compared to PCI, which has been preferred in recent years.

  Obviously, it takes quite a long time to reduce cardiovascular risk through glycemic control. According to the authors, when treating patients aged 70–80 years with multiple comorbidities, a doctor who intends to somewhat tighten glycemic control in this group of patients should clearly understand the goals he hopes to achieve. Tightening of glycemic control is often associated with an increase in the frequency of episodes of hypoglycemia and a deterioration in the quality of life with many restrictions in the patient's daily life. The tight glycemic control required for cardio- and retinoprotection is of no value if patients are constantly in a state of hypoglycemia.

  Extremely important, the authors believe, is an individual approach to the patient with a discussion of the desirability or undesirability for the patient of certain restrictions associated with treatment. This approach requires an open and honest discussion with the patient of all possible treatment options and ways to achieve therapeutic goals. With age, patients are less likely to adhere to strict glycemic control, taking into account all the difficulties that accompany it. Quality of life is a category that practitioners should not ignore.

  Another group of patients who would benefit from less aggressive glycemic control are patients with long-term diabetes mellitus and autonomic neuropathy. Such patients, as a rule, lose the ability to feel the symptoms of hypoglycemia and, if this condition develops, become more vulnerable to its negative effects. Therefore, tight glycemic control does not compensate for the risk of developing hypoglycemic conditions in this category of patients.

  With regard to revascularization, the authors of the Guidelines believe that the recently published results of the FREEDOM study convincingly demonstrated the benefits of coronary artery bypass grafting in patients with diabetes mellitus with CAD compared with PCI, even when using eluting stents. Thus, the changes in the updated Guidelines address the benefits of complete revascularization by performing bypass surgery using arterial grafts, when possible, compared to PCI. The patient may choose to undergo the PCI procedure, however, in such cases, the patient should be informed of the differences in morbidity and even mortality several years after bypass and stenting.

  Manifestations of arterial hypertension are accompanied by significant negative changes in the state of human health, therefore, the diagnosis of this serious lesion of the cardiac vascular system can be carried out at an early stage of its development. Clinical recommendations for arterial hypertension are quite specific, since this disease tends to rapidly worsen with many negative health consequences.

  Features of the therapeutic effect in hypertension

  An increase in blood pressure is accompanied by significant organic changes and is a real threat to human health. Pressure indicators should be constantly monitored, the treatment prescribed by a cardiologist should be taken at the prescribed frequency and frequency.

  The main goal of the therapeutic effect in hypertension is to lower blood pressure, which becomes possible by eliminating the causes of this condition and eliminating the consequences of hypertension. Since the causes of the disease can be both a hereditary factor and many external causes that provoke a persistent increase in pressure, their determination will help to maintain the positive result of treatment for the longest possible time and prevent relapses.

  The main points in the treatment of hypertension should be called the following:

  1. Elimination of ongoing organic diseases in parallel, which can become provoking factors for the development of hypertension.
  2. Nutrition correction, which should contain a minimum amount of foods rich in fats and cholesterol, which tends to be deposited inside the vessels and interfere with the normal movement of blood through them.
  3. Taking medications that will ensure the normalization of blood circulation in the vessels, prevent oxygen starvation of tissues and restore the normal metabolic process in them.
  4. Monitoring the patient's condition throughout the entire period of treatment, which will make it possible to make the necessary adjustments to the process of therapeutic exposure in a timely manner.

  The introduction of the required level of physical activity will speed up the processes of regeneration and removal of toxins from the body, which contributes to a more active movement of blood through the vessels, which makes it possible to quickly eliminate the causes that provoke a persistent rise in pressure.

  The risk of aggravation of arterial hypertension consists in the high probability of developing such conditions dangerous for the health and life of the patient as coronary heart disease, heart and kidney failure, and a stroke condition. Therefore, in order to prevent the listed pathological conditions, one should pay attention to blood pressure indicators in a timely manner, which will avoid further aggravation and preserve the patient's health, and in some cases, with advanced forms of diseases, his life.

  

  Risk factors for hypertension

  In hypertension, the most severe conditions occur with the following provoking factors:

  • belonging to the male sex;
  • age over years;
  • smoking and drinking alcohol;
  • elevated blood cholesterol levels;
  • overweight and obesity;
  • metabolic disorders;
  • hereditary factor.

  The listed provoking factors can become the starting point in the development of hypertension, therefore, if there is at least one of them, and even more so several, you should be attentive to your own health, eliminate, if possible, situations and conditions that can cause an exacerbation of hypertension. The start of treatment when an early stage of the disease is detected allows minimizing the risks of further development of the pathology and its transition to a more complex form.

  Tips for the prevention and treatment of arterial hypertension, taking into account the characteristics of the patient's body, will quickly eliminate the manifestations of the disease, maintain the health of the cardiovascular system. Any medicines should be taken only as prescribed by a cardiologist who made an updated diagnosis based on the tests and studies performed.

  

  Hypertension is a condition in which most of the organs and their tissues do not receive the necessary amount of substances and oxygen they need, which causes a deterioration in their condition and the functioning of the whole organism.

  • taking into account the fact that arterial hypertension is now being diagnosed at an increasingly young age, which requires monitoring the health status of all population groups;
  • preliminary diagnostics with the formulation of a refined diagnosis, which will enable more effective treatment;
  • application of the drug ranking method with the initial use of monotherapy;
  • taking drugs prescribed by a doctor to lower blood pressure according to a strict scheme;
  • take into account the age indicator when drawing up a treatment regimen for hypertension, people over 80 years of age should be treated according to a special scheme, taking into account their age and health status.

  Emergency care for hypertensive crisis

  Emergency care for a hypertensive crisis is provided, trying to achieve a decrease in blood pressure in the patient as soon as possible so that there is no severe damage to the internal organs.

  Assess the effect of the tablet taken after 30-40 minutes. If blood pressure has decreased by 15-25%, it is undesirable to further reduce it sharply, this is enough. If the medication fails to alleviate the patient's condition, you need to call an ambulance.

  

  An early visit to a doctor, calling an ambulance in case of a hypertensive crisis will provide effective treatment and help avoid irreversible complications.

  • The best way to cure hypertension (fast, easy, healthy, without "chemical" drugs and dietary supplements)
  • Hypertension - a folk way to recover from it at stages 1 and 2
  • Causes of hypertension and how to eliminate them. Tests for hypertension
  • Effective treatment of hypertension without drugs

  When you call an ambulance to call an emergency team, you need to clearly formulate the patient's complaints and the numbers of his blood pressure to the dispatcher. As a rule, hospitalization is not carried out if the patient's hypertensive crisis is not complicated by lesions of the internal organs. But be prepared for the fact that hospitalization may be required, especially if a hypertensive crisis has occurred for the first time.

  Emergency care for a hypertensive crisis before the arrival of an ambulance is as follows:

  • The patient should take a semi-sitting position in bed with the help of pillows. This is an important measure for the prevention of suffocation, shortness of breath.
  • If the patient is already being treated for hypertension, then he needs to take an extraordinary dose of his antihypertensive medication. Remember that the drug will work most effectively if taken sublingually, that is, dissolve the tablet under the tongue.
  • You should strive to reduce blood pressure by 30 mm. rt. Art. within half an hour and by 40-60 mm. rt. Art. within 60 minutes from the initial figures. If such a decrease has been achieved, then additional doses of drugs that lower blood pressure should not be taken. It is dangerous to abruptly "knock down" blood pressure to normal values, because this can lead to irreversible disorders of cerebral circulation.
  • You can take a sedative drug, such as Corvalol, to normalize the psycho-emotional state of the patient, relieve him of fear, excitability, anxiety.
  • A patient with a hypertensive crisis before the arrival of a doctor should not take any new, unusual drugs for him unless absolutely necessary. This is an unjustified risk. It is better to wait for the arrival of the emergency medical team, which will select the most appropriate drug and inject it. The same doctors, if necessary, will decide on the hospitalization of the patient in a hospital or further treatment on an outpatient basis (at home). After stopping the crisis, you need to consult a general practitioner or cardiologist to choose the best antihypertensive agent for the “planned” treatment of hypertension.

  A hypertensive crisis can happen for one of two reasons:

  1. Jumped pulse, usually above 85 beats per minute;
  2. The blood vessels narrowed, blood flow through them is difficult. In this case, the pulse is not elevated.

  The first option is called a hypertensive crisis with high sympathetic activity. The second - sympathetic activity is normal.

  • Kapoten (captopril)
  • Corinfar (nifedipine)
  • Clonidine (clonidine)
  • Physiotens (moxonidine)
  • Other possible drugs - about 20 drugs are described here

  Conducted a comparative study of the effectiveness of different tablets - nifedipine, captopril, clonidine and physiotens. 491 patients who applied for emergency care for hypertensive crisis participated. In 40% of people, the pressure jumps due to the fact that the pulse rises sharply. People most often take captopril to quickly bring down the pressure, but for patients who have an increased heart rate, it does not help well. If sympathetic activity is high, then the effectiveness of captopril is no more than 33-55%.

  If the pulse is high, then it is better to take clonidine. It works quickly and powerfully. However, clonidine in a pharmacy without a prescription may not be sold. And when the hypertensive crisis has already happened, then it’s too late to bother about the recipe. Also from clonidine there are the most frequent and unpleasant side effects. An excellent alternative to it is the drug Physiotens (moxonidine). Side effects from it are rare, and it is easier to buy it in a pharmacy than clonidine. Do not treat hypertension with clonidine daily! This is very harmful. The risk of heart attack and stroke is increased. The life expectancy of hypertensive patients is reduced by several years. Physiotens from pressure can be taken daily only as directed by a doctor.

  In the same study, doctors found that nifedipine lowered blood pressure in patients, but also increased heart rate in many of them. This can provoke a heart attack. Other tablets - capoten, clonidine and physiotens - do not exactly increase the pulse, but rather decrease it. Therefore, they are more secure.

  Side effects of emergency pills for hypertensive crisis

  Note. If there was dizziness, increased headache and a feeling of heat from taking physiotens or clofenine, then it is likely to pass quickly and without consequences. These are not serious side effects.

  

  • If such sensations arose for the first time - urgently take 1 tablet of nitroglycerin or nitrosorbide under the tongue, 1 tablet of aspirin and call an ambulance!
  • If within 5-10 minutes after taking 1 tablet of nitroglycerin under the tongue the pain does not go away, take the same dose again. A maximum of three nitroglycerin tablets can be used consecutively. If after this pain, burning sensation, pressure and discomfort behind the sternum persist, you need to urgently call an ambulance!
  • Complications of a hypertensive crisis: angina pectoris and heart attack
  • Aortic aneurysm - a complication of hypertensive crisis
  • When hypertension requires urgent hospitalization

  If you have a palpitation, "interruptions" in the work of the heart

  • Count the pulse, if it is more than 100 beats per minute or it is irregular, call an ambulance! Doctors will take an electrocardiogram (ECG) and make the right decision regarding further treatment tactics.
  • You cannot take antiarrhythmic drugs on your own unless you have previously undergone a full examination by a cardiologist and your doctor has not given specific instructions in case of an arrhythmia attack.
  • On the contrary, if you know what kind of arrhythmia you have, the diagnosis was established based on the results of a full examination by a cardiologist, you are already taking one of the antiarrhythmic drugs or, for example, you know which drug “relieves” your arrhythmia (and if it is recommended by your doctor), then you You can use it at the dosage prescribed by your doctor. Keep in mind that arrhythmia often goes away on its own within a few minutes or a few hours.

  Patients with high blood pressure should know that the best prevention of a hypertensive crisis is the regular use of a blood pressure lowering drug prescribed by your doctor. The patient should not, without consulting a specialist, abruptly cancel his own antihypertensive drug, reduce its dosage or replace it with another one.

  • Complicated and uncomplicated hypertensive crisis: how to distinguish
  • Stroke - a complication of a hypertensive crisis - and how to treat it
  • How to treat a hypertensive crisis in pregnant women, after surgery, with severe burns and with the abolition of clonidine

  Angina pectoris: tension and rest, stable and unstable - signs, treatment

  One of the most common clinical manifestations of IHD (ischemic heart disease) is angina pectoris. It is also called "angina pectoris", although this definition of the disease has recently been used very rarely.

  Symptoms

  The name is associated with the signs of the disease, which are manifested in a feeling of pressure or compression (narrow - stenos from Greek), a burning sensation in the region of the heart (kardia), behind the sternum, turning into pain.

  In most cases, the pain comes on suddenly. In some people, the symptoms of angina pectoris are pronounced in stressful situations, in others - during overexertion during heavy physical work or sports exercises. In still others, seizures cause them to wake up in the middle of the night. Most often, this is due to stuffiness in the room or too low ambient temperature, high blood pressure. In some cases, an attack occurs when overeating (especially at night).

  The duration of pain is no more than 15 minutes. But they can give in the forearm, under the shoulder blades, neck and even jaw. Often an attack of angina pectoris is manifested by unpleasant sensations in the epigastric region, for example, heaviness in the stomach, stomach cramps, nausea, heartburn. In most cases, pain disappears as soon as a person’s emotional arousal is removed, if he stops while walking, takes a break from work. But sometimes, to stop the attack, you need to take drugs from the nitrate group, which have a short effect (nitroglycerin tablet under the tongue).

  There are many cases when the symptoms of an angina attack appear only in the form of discomfort in the stomach or headaches. In this case, the diagnosis of the disease causes certain difficulties. It is also necessary to distinguish painful attacks of angina pectoris from symptoms of myocardial infarction. They are short-term, and are easily removed by taking nitroglycerin or nidefilin. While the pain of a heart attack with this drug is not stopped. In addition, with angina pectoris, there is no congestion in the lungs and shortness of breath, the body temperature remains normal, the patient does not experience excitation during an attack.

  Often this disease is accompanied by cardiac arrhythmia. External signs of angina pectoris and cardiac arrhythmias are manifested in the following:

  • Paleness of the skin of the face (in atypical cases, redness is observed);
  • Beads of cold sweat on the forehead;
  • On the face - an expression of suffering;
  • Hands - cold, with loss of sensation in the fingers;
  • Breathing - superficial, rare;
  • The pulse at the beginning of the attack is frequent, towards the end of its frequency decreases.

  Etiology (causes of occurrence)

  The most common causes of this disease are atherosclerosis of the coronary vessels and hypertension. Angina is thought to be caused by a decrease in oxygen supply to the coronary vessels and heart muscle, which occurs when blood flow to the heart does not meet its needs. This causes myocardial ischemia, which, in turn, contributes to the disruption of the oxidation processes occurring in it and the appearance of an excess of metabolic products. Often, the heart muscle requires an increased amount of oxygen with severe left ventricular hypertrophy. The reason for this are diseases such as dilated or hypertrophic cardiomyopathy, aortic regurgitation, aortic valve stenosis.

  

  Very rarely (but such cases have been noted), angina pectoris occurs against the background of infectious and allergic diseases.

  Course of the disease and prognosis

  This disease is characterized by a chronic course. Seizures may recur when performing heavy work. Often they occur when a person is just starting to move (walking), especially in cold and humid weather, on sweltering summer days. Subject to angina attacks are emotional, mentally unbalanced people who are subject to frequent stress. There have been cases when the first attack of angina led to death. In general, with the right method of treatment, following the recommendations of doctors, the prognosis is favorable.

  Treatment

  To eliminate angina attacks are used:

  1. Conservative methods of treatment, including drug (drug) and non-drug therapy;
  2. Surgery.

  Treatment of angina pectoris with drugs is carried out by a cardiologist. It includes the following:

  Medications

  Result to be achieved

  1	ACE and f-channel inhibitors, b-blockers	Maintaining normal blood pressure, reducing heart rate and myocardial oxygen consumption, increasing the degree of exercise tolerance
  2	Lipid-lowering drugs: Omega-3 polyunsaturated fatty acids, fibrates, statites	Slowdown and stabilization of the formation of atherosclerotic plaques
  3	Antiplatelet agents (antithrombotics)	Prevention of thrombus formation in coronary vessels
  4	calcium antagonists	Prevention of coronary spasms in vasospastic angina
  5	Short-acting nitrates (nitroglycerin, etc.)	Relief of an attack
  6	Long acting nitrates	They are prescribed as a prophylactic before an increased and prolonged load or a possible surge of emotions.

  Non-drug treatments include:

  • The use of diets aimed at lowering cholesterol levels in the blood;
  • Bringing body weight in line with its growth index;
  • Development of individual loads;
  • Treatment by means of alternative medicine;
  • Elimination of bad habits: smoking, drinking alcohol, etc.

  Surgical treatment includes atherotomy, rotoblation, coronary angioplasty, in particular with stenting, as well as a complex operation - coronary artery bypass grafting. The method of treatment is selected depending on the type of angina pectoris and the severity of the course of the disease.

  Classification of angina pectoris

  The following classification of the disease is accepted:

  • Due to occurrence:
    1. Angina pectoris that occurs under the influence of physical activity;
    2. Rest angina, the attacks of which overtake the patient during night sleep, and during the day, when he is in the supine position, without obvious prerequisites.
  • According to the nature of the course: Prinzmetal's angina pectoris is distinguished as a separate type.
    1. stable. Attacks of the disease appear with a certain, predictable frequency (for example, every other day or two, several times a month, etc.). It is divided into functional classes (FC) from I to IV.
    2. Unstable. First emerging (VVS), progressive (PS), postoperative (early pre-infarction), spontaneous (variant, vasospastic).

  Each species and subspecies has its own characteristics and features of the course of the disease. Let's consider each of them.

  Stable exertional angina

  The Academy of Medical Sciences conducted studies on what types of physical work people with diseases of the cardiovascular system can do without experiencing discomfort and seizures in the form of heaviness and pain in the chest. At the same time, stable exertional angina was divided into four functional classes.

  I functional class

  It is called latent (hidden) angina pectoris. It is characterized by the fact that the patient can perform almost all types of work. He easily overcomes long distances on foot, easily climbs the stairs. But only if all this is done measuredly and for a certain time. With the acceleration of movement, or an increase in the duration and pace of work, an angina attack occurs. Most often, such attacks appear during extreme stress for a healthy person, for example, when resuming sports, after a long break, performing unbearable physical activity, etc.

  Most people suffering from angina pectoris of this FC consider themselves healthy people and do not seek medical help. However, coronary angiography shows that they have moderate individual vessel lesions. Carrying out a bicycle ergometric test also gives a positive result.

  II functional class

  People with angina of this functional class often experience attacks at certain hours, for example, in the morning after waking up and getting out of bed abruptly. In some, they appear after climbing the stairs of a certain floor, in others - while moving in bad weather. Reducing the number of seizures, contributes to the proper organization of work and the distribution of physical activity. Doing them at the right time.

  

  III functional class

  Angina pectoris of this type is inherent in people with strong psycho-emotional arousal, in whom attacks appear when moving at a normal pace. And overcoming the stairs to their floor turns into a real test for them. These people often experience rest angina. They are the most frequent patients in hospitals diagnosed with coronary artery disease.

  IV functional class

  In patients with angina pectoris of this functional class, any kind of physical activity, even minor, causes an attack. Some are not even able to move around the apartment, without pain in the chest. Among them, the largest percentage of patients in whom pain occurs at rest.

  Unstable angina

  Angina pectoris, the number of attacks of which can either increase or decrease; their intensity and duration at the same time also changes, is called unstable or progressive. Unstable angina (UA) is distinguished by the following features:

  • The nature and severity of the occurrence:
    1. Class I. The initial stage of chronic angina. The first signs of the onset of the disease were noted shortly before going to the doctor. In this case, the exacerbation of coronary artery disease is less than two months.
    2. Class II. Subacute flow. Pain syndromes were noted during the entire month preceding the date of the visit to the doctor. But for the last two days they have been absent.
    3. Class III. The current is sharp. Attacks of stenocardia were observed at rest during the last two days.
  • Occurrence conditions:
    1. Group A. Unstable, secondary angina pectoris. The cause of its development are factors provoking coronary artery disease (hypotension, tachyarrhythmia, uncontrolled hypertension, infectious diseases accompanied by fever, anemia, etc.)
    2. Group B. Unstable, primary angina. It develops in the absence of factors that increase the course of IHD.
    3. Group C. Early postinfarction angina pectoris. Occurs in the coming weeks, after suffering an acute myocardial infarction.
  • Against the background of ongoing therapeutic treatment:
    1. It develops with a minimum of medical procedures (or their absence).
    2. With a course of medication.
    3. Development continues with intensive treatment.

  rest angina

  Patients diagnosed with functional class IV stable angina almost always complain of pain at night and early in the morning when they just woke up and are in bed. The examination of the cardiological and hemodynamic processes of such patients, through continuous daily monitoring, proves that the harbinger of each attack is an increase in blood pressure (diastolic and systolic) and an increase in heart rate. In some people, the pressure was high in the pulmonary artery.

  

  Resting angina is a more severe course of exertional angina. Most often, the onset of an attack is preceded by a psycho-emotional load that causes an increase in blood pressure.

  It is much more difficult to stop them, since the elimination of the cause of their occurrence is fraught with certain difficulties. After all, any occasion can serve as a psycho-emotional load - a conversation with a doctor, a family conflict, troubles at work, etc.

  When an attack of this type of angina occurs for the first time, many people experience a feeling of panic fear. They are afraid to move. After the pain passes, the person experiences a feeling of excessive fatigue. Beads of cold sweat break out on his forehead. The frequency of seizures is different for everyone. In some, they can manifest themselves only in critical situations. Other attacks are visited more than 50 times a day.

  One type of rest angina is vasospastic angina. The main cause of seizures is a spasm of the coronary vessels that occurs suddenly. Sometimes this occurs even in the absence of atherosclerotic plaques.

  Many older people have spontaneous angina that occurs in the early morning hours, at rest, or when they change position. At the same time, there are no visible prerequisites for seizures. In most cases, their occurrence is associated with nightmares, a subconscious fear of death. Such an attack can last a little longer than other types. Often it is not stopped by nitroglycerin. All this is angina pectoris, the signs of which are very similar to the symptoms of myocardial infarction. If you make a cardiogram, it will be seen that the myocardium is in the stage of dystrophy, but there are no clear signs of a heart attack and enzyme activity indicating it.

  Prinzmetal's angina

  Prinzmetal's angina is a special, atypical and very rare type of coronary heart disease. She received this name in honor of the American cardiologist who first discovered it. A feature of this type of disease is the cyclical occurrence of seizures that follow one after another, with a certain interval of time. Usually they make up a series of attacks (from two to five) that always occur at the same time - in the early morning. Their duration can be from 15 to 45 minutes. Often this type of angina is accompanied by severe arrhythmia.

  It is believed that this type of angina pectoris is a disease of young people (up to 40 years old). It rarely causes a heart attack, but it can contribute to the development of life-threatening arrhythmias, such as ventricular tachycardia.

  The nature of pain in angina pectoris

  

  Most people with angina pectoris complain of chest pain. Some characterize it as pressing or cutting, in others it is felt as constricting the throat or burning the heart. But there are many patients who cannot accurately convey the nature of the pain, as it radiates to various parts of the body. The fact that this is angina pectoris is often indicated by a characteristic gesture - a clenched fist (one or both palms) attached to the chest.

  Pain in angina pectoris usually follows one after another, gradually intensifying and growing. Having reached a certain intensity, they almost immediately disappear. Angina pectoris is characterized by the onset of pain at the moment of exercise. Pain in the chest, which appears at the end of the working day, after the completion of physical work, has nothing to do with coronary heart disease. Do not worry if the pain lasts only a few seconds, and disappears with a deep breath or a change in position.

  Video: Lecture on angina pectoris and coronary heart disease at St. Petersburg State University

  At-risk groups

  There are features that can provoke the occurrence of various types of angina pectoris. They are called risk groups (factors). There are the following risk groups:

  • Unmodified - factors that a person cannot influence (eliminate). These include:
    1. Heredity (genetic predisposition). If someone in the male family died before the age of 55 from heart disease, then the son is at risk of angina pectoris. In the female line, the risk of disease occurs if death is frowning from heart disease before the age of 65.
    2. Racial affiliation. It has been noted that residents of the European continent, in particular northern countries, have angina pectoris much more often than residents of southern countries. And the lowest percentage of the disease is in representatives of the Negroid race.
    3. Gender and age. Before the age of 55, angina is more common in men than in women. This is due to the high production of estrogens (female sex hormones) during this period. They are a reliable protection of the heart from various diseases. However, during menopause, the picture changes and the risk of angina in both sexes becomes equal.
  • Modified - a risk group in which a person can influence the causes of the development of the disease. It includes the following factors:
    1. Overweight (obesity). With weight loss, the level of cholesterol in the blood decreases, blood pressure decreases, which invariably reduces the risk of angina pectoris.
    2. Diabetes. By keeping blood sugar levels close to normal, the frequency of CHD attacks can be controlled.
    3. Emotional loads. You can try to avoid many stressful situations, which means reducing the number of angina attacks.
    4. High blood pressure (hypertension).
    5. Low physical activity (hypodynamia).
    6. Bad habits, in particular smoking.

  Emergency care for angina pectoris

  People diagnosed with progressive angina (and other types) are at risk for sudden death and myocardial infarction. Therefore, it is important to know how to quickly cope with the main symptoms of the disease on your own, and when the intervention of medical professionals is required.

  In most cases, this disease is manifested by the occurrence of sharp pain in the chest area. This happens due to the fact that the myocardium experiences oxygen starvation due to a reduced supply of blood during exercise. First aid during an attack should be aimed at restoring blood flow.

  Therefore, every angina patient should carry a fast-acting vasodilator, such as nitroglycerin, with them. At the same time, doctors recommend taking it shortly before the alleged onset of an attack. This is especially true if an emotional outburst is foreseen or hard work is to be done.

  

  If you notice a walking person on the street who suddenly froze, turned very pale and involuntarily touches his chest with his palm or clenched fist, this means that he was overtaken by an attack of coronary heart disease and urgent care is required for angina pectoris.

  In order to provide it, you need to do the following:

  1. If possible, seat a person (if there is no bench nearby, then directly on the ground).
  2. Open his chest by undoing the button.
  3. Look for a saving pill of nitroglycerin (valocordin or validol) from him and put it under his tongue.
  4. Keep track of the time, if within one or two minutes he does not feel better, then you need to call an ambulance. At the same time, before the arrival of the doctors, it is advisable to stay close to him, trying to involve him in a conversation on abstract topics.
  5. After the arrival of the doctors, try to clearly explain to the doctors the picture of what is happening, since the onset of the attack.

  Today, fast-acting nitrates come in a variety of forms that work instantly and are much more effective than tablets. These are aerosols called Nitro poppy, Isotket, Nitrospray.

  The way to use them is as follows:

  • Shake the bottle
  • Direct the spraying device into the patient's oral cavity,
  • Make him hold his breath, inject one dose of aerosol, trying to get under the tongue.

  In some cases, it may be necessary to inject the medicine again.

  Similar assistance should be provided to the patient at home. It will relieve an acute attack and may turn out to be saving, preventing myocardial infarction from developing.

  Diagnostics

  After providing the first necessary aid, the patient must definitely see a doctor who will clarify the diagnosis and select the optimal treatment. For this, a diagnostic examination is carried out, consisting of the following:

  1. A medical history is compiled from the words of the patient. Based on the patient's complaints, the doctor establishes the preliminary causes of the disease. After checking blood pressure and pulse, measuring heart rate, the patient is sent for laboratory diagnostics.
  2. Blood samples are analyzed in the laboratory. Important is the analysis for the presence of cholesterol plaques, which are prerequisites for the occurrence of atherosclerosis.
  3. Instrumental diagnostics is carried out:
     • Holter monitoring, during which the patient wears a portable recorder during the day, which records the ECG and transfers all the information received to the computer. Thanks to this, all violations in the work of the heart are detected.
     • Stress tests to study the reaction of the heart to various types of stress. According to them, classes of stable angina pectoris are determined. Testing is carried out on a treadmill (treadmill) or bicycle ergometer.
     • To clarify the diagnosis for pain, which is not a fundamental factor in angina pectoris, but is also inherent in other diseases, computed multislice tomography is performed.
     • Choosing the optimal method of treatment (between conservative and operative), the doctor can refer the patient to coronary angiography.
     • If necessary, to determine the severity of damage to the heart vessels, an EchoCG (endovascular echocardiography) is performed.

  Video: Diagnosis of elusive angina

  Drugs for the treatment of angina pectoris

  Medicines are needed to reduce the frequency of attacks, reduce their duration and prevent the development of myocardial infarction. They are recommended for anyone who suffers from any kind of angina pectoris. The exception is the presence of contraindications to taking a particular drug. A cardiologist selects a medicine for each individual patient.

  

  Video: Opinion of a specialist on the treatment of angina pectoris with an analysis of a clinical case

  Alternative medicine in the treatment of angina pectoris

  Today, many people are trying to treat various diseases with alternative medicine methods. Some are addicted to them, sometimes reaching fanaticism. However, we must pay tribute to the fact that many traditional medicines help to cope with angina attacks, without the side effects inherent in some drugs. If treatment with folk remedies is carried out in combination with drug therapy, then the number of seizures that occur can be significantly reduced. Many medicinal plants have a calming and vasodilating effect. And you can use them instead of regular tea.

  One of the most effective remedies that strengthen the heart muscle and reduce the risk of heart and vascular disease is a mixture that includes lemons (6 pieces), garlic (head) and honey (1 kg). Lemons and garlic are crushed and poured with honey. The mixture is infused for two weeks in a dark place. Take a teaspoon in the morning (on an empty stomach) and in the evening (before going to bed).

  You can read more about this and other methods of cleansing and strengthening blood vessels here.

  No less healing effect is given by breathing exercises according to the Buteyko method. She teaches how to breathe correctly. Many patients who mastered the technique of breathing exercises got rid of blood pressure surges and learned to tame angina attacks, regaining the opportunity to live a normal life, play sports and physical labor.

  Prevention of angina pectoris

  Everyone knows that the best treatment for a disease is its prevention. To always be in good shape, and not grab your heart at the slightest increase in load, you must:

  1. Watch your weight, trying to prevent obesity;
  2. Forever forget about smoking and other bad habits;
  3. Timely treat concomitant diseases that can become a prerequisite for the development of angina pectoris;
  4. With a genetic predisposition to heart disease, devote more time to strengthening the heart muscle and increasing the elasticity of blood vessels by visiting the physiotherapy room and strictly following all the advice of the attending physician;
  5. Lead an active lifestyle, because physical inactivity is one of the risk factors in the development of angina pectoris and other diseases of the heart and blood vessels.

  

  Today, almost all clinics have exercise therapy rooms, the purpose of which is the prevention of various diseases and rehabilitation after complex treatment. They are equipped with special simulators and devices that control the work of the heart and other systems. The doctor who conducts classes in this office selects a set of exercises and a load that is suitable for a particular patient, taking into account the severity of the disease and other features. By visiting it, you can significantly improve your health.

  Video: Angina - how to protect your heart?

  Ischemic heart disease is a common cardiovascular pathology resulting from impaired blood supply to the myocardium.

  Ischemic heart disease is the most common in Russia among all cardiovascular diseases.

  In 28% of cases, it is she who is the reason for the treatment of adults in medical institutions.

  At the same time, only half of the patients with coronary artery disease know that they have this pathology and receive treatment, in all other cases, ischemia remains unrecognized, and its first manifestation is acute coronary syndrome or myocardial infarction.

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  ICD-10 diagnoses

  1. I20.1 Angina pectoris with documented spasm
  2. I20.8 Other angina pectoris
  3. I20.9 Angina pectoris, unspecified
  4. I25 Chronic ischemic heart disease

  Ischemic heart disease is a lesion of the heart muscle associated with impaired blood flow through the coronary arteries.

  This violation, in turn, is organic (irreversible) and functional (transient).

  In the first case, the main cause of IHD is stenosing atherosclerosis. Factors of functional damage to the coronary arteries are spasms, transient platelet aggregation, and intravascular thrombosis.

  The concept of "ischemic heart disease" includes both acute transient (unstable) and chronic (stable) conditions.

  Most often, the main causes of CAD are stable anatomical atherosclerotic and/or functional stenosis of the epicardial vessels and/or microvascular dysfunction.

  The main risk factors for coronary heart disease:

  1. High blood cholesterol.
  2. Diabetes.
  3. arterial hypertension.
  4. Sedentary lifestyle.
  5. Tobacco smoking.
  6. Overweight, obesity.

  ✔ Distribution of patients with coronary artery disease according to the degree of risk based on non-invasive diagnostic methods, download the table in the Consilium System.

  

  Download table

  In addition, risk factors for CHD that cannot be influenced are:

  • belonging to the male sex;
  • age;
  • burdened heredity.

  In addition, there are social risk factors that increase the incidence of CHD among the population of developing countries:

  • urbanization;
  • industrialization;
  • economic backwardness of the population.

  Ischemia in humans develops when the need of the heart muscle for oxygen exceeds the ability to deliver it with blood through the coronary arteries.

  The mechanisms for the development of coronary artery disease are:

  • a decrease in coronary reserve (the ability to increase coronary blood flow with an increase in the metabolic needs of the myocardium);
  • primary decrease in coronary blood flow.

  The oxygen demand of the heart muscle is determined by three factors:

  1. Tension of the walls of the left ventricle.
  2. Myocardial contractility.

  The higher the value of each of these indicators, the higher the myocardial oxygen demand.

  The amount of coronary blood flow depends on:

  • coronary artery resistance;
  • heart rate;
  • perfusion pressure (the so-called difference between diastolic pressure in the aorta and the same in the left ventricle).

  angina pectoris

  Angina pectoris is the most common form of cardiac ischemia. Its frequency increases with age in both men and women. Annual lethality from coronary artery disease is about 1.2-2.4%, and 0.6-1.4% of patients die from fatal cardiovascular complications every year, while the percentage of non-fatal myocardial infarctions is 0.6-2, 7 per year.

  However, in subpopulations with various additional risk factors, these values ​​may be different.

  Patients diagnosed with stable angina pectoris die from ischemia 2 times more often than patients without this diagnosis. There are currently no epidemiological data on microvascular and vasospastic angina.

  Revascularization of the heart muscle in order to stop angina attacks, reduce its functional class and improve the quality of life is recommended for all patients with angina pectoris in the presence of coronary stenosis > 50 percent with documented myocardial ischemia or fractional blood flow reserve (FRF) ≤ 0.80 in combination with angina pectoris (and / or its equivalents), refractory to drug therapy.

  It must be said that for coronary artery stenoses less than 90%, additional tests are needed to prove their hemodynamic significance (documented myocardial ischemia, including according to stress tests with myocardial imaging or determination of FFR).

  Myocardial revascularization to improve the prognosis of the underlying pathology is indicated in all patients with a large area of ​​ischemia (>10% in the left ventricle), as well as in all patients with a single preserved artery with >50% stenosis.

  Surgery on the coronary arteries improves the prognosis of patients with extensive ischemia.

  A large zone of damage to the heart muscle can be judged by the presence of a hemodynamically important lesion of a large coronary artery:

  • trunk of the left coronary artery;
  • proximal anterior descending artery;
  • two- or three-vessel lesions with a decrease in left ventricular function;
  • the only surviving coronary vessel.

  When choosing a method, factors such as:

  1. Anatomical features of coronary artery lesions.
  2. Associated diseases and possible risks.
  3. Consent of the patient to a specific method of surgical treatment.

  In the event that both AOS and PCI with stenting are possible, and the patient agrees to any type of intervention, the choice of technique is determined by the anatomical features of the coronary lesion.

  Ischemic heart disease: treatment

  The conservative treatment of stable cardiac ischemia is based on the elimination of risk factors that can be influenced, as well as complex drug treatment. The patient must be informed of all risks and of the treatment strategy.

  When collecting anamnesis and examination, it is necessary to pay attention to comorbidities, especially when it comes to arterial hypertension, diabetes mellitus and hypercholesterolemia.

  Eliminating risk factors is a complex and indefinitely long task. The most important role here is played by informing and educating the patient, since only an informed and trained patient will clearly follow medical recommendations and will be able to make important decisions in the future depending on the symptoms.

  • discuss with the patient the prospects for both drug treatment and surgical intervention;
  • specify the need and frequency of instrumental and laboratory tests;
  • talk about the most common symptoms of unstable angina, AMI, emphasize the importance of promptly contacting specialists when they occur;
  • give clear recommendations on maintaining a healthy lifestyle, emphasizing the importance of treating concomitant diseases.

  Drug therapy is aimed at eliminating the clinical manifestations of coronary artery disease, as well as at preventing complications from the heart and blood vessels. It is recommended that the patient be prescribed at least one drug to eliminate the symptoms of angina pectoris in combination with prophylactic drugs.

  Coronary heart disease (CHD) has become a serious social problem, because most of the world's population has one or another of its manifestations. The rapid pace of life in megacities, psycho-emotional stress, the consumption of large amounts of fat in the diet contribute to the onset of the disease, and therefore it is not surprising that residents of developed countries are more susceptible to this problem.

  IHD is a disease associated with a change in the wall of the arterial vessels of the heart with cholesterol plaques, which ultimately leads to an imbalance between the needs of the heart muscle for the substances necessary for metabolism and the possibilities of their delivery through the cardiac arteries. The disease can proceed even acutely, even chronically, has many clinical forms that differ in symptoms and prognosis.

  Despite the emergence of various modern methods of treatment, coronary artery disease still occupies a leading position in the number of deaths in the world. Often, cardiac ischemia is combined with the so-called ischemic brain disease, which also occurs with atherosclerotic lesions of the vessels that supply it with blood. A fairly common ischemic stroke, in other words, cerebral infarction, is a direct consequence of atherosclerosis of cerebral vessels. Thus, the common causes of these serious diseases also determine their frequent combination in the same patient.

  Main cause of coronary artery disease

  In order for the heart to be able to deliver blood to all organs and tissues in a timely manner, it must have a healthy myocardium, because there are many biochemical transformations necessary to perform such an important function. The myocardium is supplied with vessels called coronary vessels, through which “food” and breathing are delivered to it. Various influences that are unfavorable for the coronary vessels can lead to their failure, which will entail a violation of the movement of blood and nutrition of the heart muscle.

  Causes of coronary heart disease modern medicine has studied quite well. With increasing age, under the influence of the external environment, lifestyle, dietary habits, as well as in the presence of a hereditary predisposition, coronary arteries are affected by atherosclerosis. In other words, protein-fat complexes are deposited on the walls of the arteries, which eventually turn into an atherosclerotic plaque, which narrows the lumen of the vessel, disrupting the normal blood flow to the myocardium. So, the immediate cause of myocardial ischemia is atherosclerosis.

  Video: IHD and atherosclerosis

  When do we take risks?

  Risk factors are conditions that pose a threat to the development of the disease, contribute to its occurrence and progression. The main factors leading to the development of cardiac ischemia can be considered the following:

  • Increased cholesterol levels (hypercholesterolemia), as well as a change in the ratio of various fractions of lipoproteins;
  • Malnutrition (abuse of fatty foods, excessive consumption of easily digestible carbohydrates);
  • Physical inactivity, low physical activity, unwillingness to play sports;
  • The presence of bad habits, such as smoking, alcoholism;
  • Concomitant diseases accompanied by metabolic disorders (obesity, diabetes mellitus, decreased thyroid function);
  • Arterial hypertension;
  • Age and sex factor (it is known that coronary artery disease is more common in older people, and also in men more often than in women);
  • Features of the psycho-emotional state (frequent stress, overwork, emotional overstrain).

  As you can see, most of the above factors are quite banal. How do they affect the occurrence of myocardial ischemia? Hypercholesterolemia, malnutrition and metabolism are prerequisites for the formation of atherosclerotic changes in the arteries of the heart. In patients with arterial hypertension, against the background of pressure fluctuations, a spasm of blood vessels occurs, in which their inner membrane is damaged, and hypertrophy (enlargement) of the left ventricle of the heart develops. It is difficult for the coronary arteries to provide sufficient blood supply to the increased mass of the myocardium, especially if they are narrowed by accumulated plaques.

  It is known that smoking alone can increase the risk of death from vascular disease by about half. This is due to the development of arterial hypertension in smokers, an increase in heart rate, an increase in blood coagulation, and an increase in atherosclerosis in the walls of blood vessels.

  Psycho-emotional stress is also referred to as risk factors. Some features of a person who has a constant feeling of anxiety or anger, which can easily cause aggression towards others, as well as frequent conflicts, lack of understanding and support in the family, inevitably lead to high blood pressure, increased heart rate and, as a result, an increasing need myocardium in oxygen.

  Video: the occurrence and course of ischemia

  Does everything depend on us?

  There are so-called non-modifiable risk factors, that is, those that we cannot influence in any way. These include heredity (the presence of various forms of coronary artery disease in the father, mother and other blood relatives), old age and gender. In women, various forms of coronary artery disease are observed less frequently and at a later age, which is explained by the peculiar action of female sex hormones, estrogens, which prevent the development of atherosclerosis.

  In newborns, young children and adolescents, there is practically no sign of myocardial ischemia, especially those caused by atherosclerosis. At an early age, ischemic changes in the heart can occur as a result of spasm of the coronary vessels or malformations. Ischemia in newborns and more often affects the brain and it is associated with violations of the course of pregnancy or the postpartum period.

  It is unlikely that each of us can boast of excellent health, constant adherence to diet and regular exercise. Large workloads, stress, constant haste, the inability to eat balanced and regular are frequent companions of our daily rhythm of life.

  It is believed that residents of megacities are more prone to the development of cardiovascular diseases, including coronary artery disease, which is associated with high stress levels, constant overwork and lack of physical activity. However, it would be nice to go to the pool or gym at least once a week, but most of us will find a lot of excuses not to do this! Someone does not have time, someone is too tired, and a sofa with a TV and a plate of delicious homemade food on the day off beckons with incredible strength.

  Many do not attach significant importance to lifestyle, so polyclinic doctors need to timely identify risk factors in patients at risk, share information about the possible consequences of overeating, obesity, a sedentary lifestyle, and smoking. The patient must clearly understand the outcome that ignoring the coronary vessels can lead to, therefore, as they say: forewarned is forearmed!

  Types and forms of coronary heart disease

  Currently, there are many types of coronary heart disease. The classification of coronary artery disease, proposed in 1979 by a working group of WHO experts, is still relevant and is used by many doctors. It is based on the allocation of independent forms of the disease, which have peculiar characteristic manifestations, a certain prognosis and require a special type of treatment. Over time and the advent of modern diagnostic methods, other forms of coronary artery disease have been studied in detail, which is reflected in other, newer classifications.

  Currently, the following clinical forms of IHD are distinguished, which are presented:

  1. Sudden coronary death (primary cardiac arrest);
  2. Angina pectoris (here, its forms such as exertional angina and spontaneous angina pectoris are distinguished);
  3. Myocardial infarction (primary, repeated, small-focal, large-focal);
  4. Postinfarction cardiosclerosis;
  5. Insufficiency of blood circulation;
  6. Violation of the heart rhythm;
  7. Painless myocardial ischemia;
  8. Microvascular (distal) CAD
  9. New ischemic syndromes ("stunning" of the myocardium, etc.)

  For statistical accounting of the incidence of coronary heart disease, the International Classification of Diseases of the 10th revision is used, with which every doctor is familiar. In addition, it should be mentioned that the disease can occur in an acute form, for example, myocardial infarction, sudden coronary death. Chronic ischemic heart disease is represented by such forms as cardiosclerosis, stable angina pectoris, chronic heart failure.

  Manifestations of myocardial ischemia

  Symptoms of cardiac ischemia are varied and are determined by the clinical form that they accompany. Many people know such signs of ischemia as pain in the chest, radiating to the left arm or shoulder, heaviness or a feeling of constriction behind the sternum, fatigue and shortness of breath even with little physical exertion. In the event of such complaints, as well as in the presence of risk factors in a person, he should be asked in detail about the features of the pain syndrome, find out what the patient feels, what conditions could provoke an attack. Usually, patients are well aware of their disease and can clearly describe the causes, frequency of attacks, intensity of pain, their duration and nature, depending on physical activity or taking certain medications.

  Sudden coronary (cardiac) death is the death of a patient, often in the presence of witnesses, occurring suddenly, instantly or within six hours of the onset of a heart attack. It is manifested by loss of consciousness, cessation of breathing and cardiac activity, dilated pupils. This condition requires urgent medical measures, and the sooner they are provided by qualified specialists, the more likely it is to save the patient's life. However, even with timely resuscitation, the death rate in this form of coronary artery disease reaches 80%. This form of ischemia can also be observed in young people, which is most often due to a sudden spasm of the coronary arteries.

  Angina pectoris and its types

  Angina pectoris is perhaps one of the most common manifestations of myocardial ischemia. It occurs, as a rule, against the background of atherosclerotic lesions of the heart vessels, however, in its genesis, an important role is played by the tendency of the vessels to spasm and an increase in the aggregation properties of platelets, which entails the formation of blood clots and blockage of the lumen of the artery. Even with minor physical exertion, the affected vessels are not able to provide normal blood flow to the myocardium, as a result, its metabolism is disturbed, and this is manifested by characteristic pain sensations. Symptoms of coronary heart disease in this case will be as follows:

  • Paroxysmal intense pain behind the sternum, radiating to the left arm and left shoulder, and sometimes to the back, shoulder blade, or even to the abdomen;
  • Violation of the heart rhythm (increase or, conversely, decrease in heart rate, the appearance of extrasystoles);
  • Changes in blood pressure (more often its increase);
  • The appearance of shortness of breath, anxiety, pallor of the skin.

  

  Depending on the causes of occurrence, there are various variants of the course of angina pectoris. It can be angina pectoris that occurs against the background of physical or emotional stress. As a rule, when taking nitroglycerin or at rest, the pain goes away.

  Spontaneous angina is a form of cardiac ischemia, which is accompanied by the appearance of pain for no apparent reason, in the absence of physical or emotional stress.

  Unstable angina pectoris is a form of progression of coronary heart disease, when there is an increase in the intensity of pain attacks, their frequency, while the risk of developing acute myocardial infarction and death increases significantly. The patient at the same time begins to consume more nitroglycerin tablets, which indicates a deterioration in his condition and a worsening of the course of the disease. This form requires special attention and urgent treatment.

  Read more about all types of angina pectoris and its treatment here.

  Myocardial infarction, what does this concept mean?

  Myocardial infarction (MI) is one of the most dangerous forms of coronary artery disease, in which necrosis (necrosis) of the heart muscle occurs as a result of a sudden cessation of blood supply to the heart. Heart attack is more common in men than in women, and this difference is more pronounced in young and adulthood. This difference can be explained by the following reasons:

  1. Later development of atherosclerosis in women, which is associated with hormonal status (after the onset of menopause, this difference begins to gradually decrease and finally disappears by the age of 70);
  2. Greater prevalence of bad habits among the male population (smoking, alcoholism).
  3. The risk factors for myocardial infarction are the same as those described above for all forms of coronary artery disease, however, in this case, in addition to narrowing the lumen of the vessels, sometimes for a considerable extent, as a rule, thrombosis also occurs.

  

  In various sources, with the development of myocardial infarction, the so-called pathomorphological triad is distinguished, which looks like this:

  The presence of an atherosclerotic plaque and its increase in size over time can lead to its rupture and release of the contents to the surface of the vascular wall. Plaque damage can be promoted by smoking, high blood pressure, and intense exercise.

  Damage to the endothelium (the inner layer of the artery) during plaque rupture causes increased blood clotting, “sticking” of platelets to the site of damage, which inevitably leads to thrombosis. According to different authors, the incidence of thrombosis in myocardial infarction reaches 90%. First, the thrombus fills the plaque, and then the entire lumen of the vessel, while the movement of blood at the site of thrombus formation is completely disrupted.

  Spasm of the coronary arteries occurs at the time and place of thrombus formation. It can also occur throughout the coronary artery. Coronarospasm leads to a complete narrowing of the lumen of the vessel and the final stop of the movement of blood through it, which causes the development of necrosis in the heart muscle.

  In addition to the reasons described, others play an important role in the pathogenesis of myocardial infarction, which are related to:

  • With a violation of the coagulation and anticoagulation systems;
  • With insufficient development of "bypass" tracts of blood circulation (collateral vessels),
  • With immunological and metabolic disorders at the site of damage to the heart muscle.

  How to recognize a heart attack?

  What are the symptoms and manifestations of myocardial infarction? How not to miss this formidable form of coronary artery disease, so often leading to the death of people?

  Often, MI finds patients in a variety of places - at home, at work, in public transport. It is important to identify this form of coronary artery disease in time in order to immediately begin treatment.

  The clinic of a heart attack is well known and described. As a rule, patients complain of acute, "dagger", retrosternal pain, which does not stop when taking nitroglycerin, changing body position or holding the breath. A painful attack can last up to several hours, while there is anxiety, a feeling of fear of death, sweating, cyanosis of the skin.

  With the simplest examination, disturbances in the rhythm of the heart, changes in blood pressure (a decrease due to a violation of the pumping function of the heart) are quickly detected. There are cases when necrosis of the heart muscle is accompanied by changes in the gastrointestinal tract (nausea, vomiting, flatulence), as well as the so-called "painless" myocardial ischemia. In these cases, diagnosis can be difficult and requires the use of additional methods of examination.

  However, with timely treatment, it becomes possible to save the patient's life. In this case, at the site of the focus of necrosis of the heart muscle, a focus of dense connective tissue will appear - a scar (the focus of post-infarction cardiosclerosis).

  Video: how the heart works, myocardial infarction

  Consequences and complications of coronary artery disease

  Postinfarction cardiosclerosis

  Postinfarction cardiosclerosis is one of the forms of coronary heart disease. A scar in the heart allows the patient to live more than one year after a heart attack. However, over time, as a result of a violation of the contractile function associated with the presence of a scar, one way or another, signs of heart failure begin to appear - another form of coronary artery disease.

  Chronic heart failure

  Chronic heart failure is accompanied by the occurrence of edema, shortness of breath, decreased tolerance to physical activity, as well as the appearance of irreversible changes in the internal organs, which can cause the death of the patient.

  Acute heart failure

  Acute heart failure can develop in any type of coronary heart disease, however, it most often occurs in acute myocardial infarction. So, it can be manifested by a violation of the work of the left ventricle of the heart, then the patient will have signs of pulmonary edema - shortness of breath, cyanosis, the appearance of foamy pink sputum when coughing.

  Cardiogenic shock

  Another manifestation of acute circulatory failure is cardiogenic shock. It is accompanied by a drop in blood pressure and a pronounced violation of the blood supply to various organs. The condition of the patients is severe, consciousness may be absent, the pulse is threadlike or not detected at all, breathing becomes shallow. In the internal organs, as a result of a lack of blood flow, dystrophic changes develop, foci of necrosis appear, which leads to acute renal and hepatic failure, pulmonary edema, and dysfunction of the central nervous system. These conditions require immediate action, because they directly represent a mortal danger.

  

  Arrhythmia

  Heart rhythm disturbances are quite common among patients with cardiac pathology, they often accompany the above forms of coronary artery disease. Arrhythmias can either not significantly affect the course and prognosis of the disease, or significantly worsen the patient's condition and even pose a threat to life. Among the arrhythmias, the most common are sinus tachycardia and bradycardia (increase and slowdown in the frequency of heart contractions), extrasystole (appearance of extraordinary contractions), disturbances in the conduction of impulses through the myocardium - the so-called blockade.

  Methods for diagnosing coronary heart disease

  Currently, there are many modern and diverse methods for detecting coronary blood flow disorders and cardiac ischemia. However, one should not neglect the simplest and most accessible, such as:

  1. Careful and detailed questioning of the patient, collection and analysis of complaints, their systematization, clarification of family history;
  2. Inspection (detection of the presence of edema, discoloration of the skin);
  3. Auscultation (listening to the heart with a stethoscope)
  4. Carrying out various tests with physical activity, in which there is a constant monitoring of the activity of the heart (veloergometry).

  These simple methods in most cases make it possible to accurately determine the nature of the disease and determine a further plan for the examination and treatment of the patient.

  Instrumental research methods help to more accurately determine the form of coronary artery disease, the severity of the course and prognosis. Most often used:

  • electrocardiography is a very informative method for diagnosing various types of myocardial ischemia, since ECG changes in various conditions have been studied and described quite well. ECG can also be combined with dosed physical activity.
  • biochemical blood test (detection of lipid metabolism disorders, the appearance of signs of inflammation, as well as specific enzymes that characterize the presence of a necrotic process in the myocardium).
  • coronary angiography, which allows, by introducing a contrast agent, to determine the localization and prevalence of lesions of the coronary arteries, the degree of their narrowing by a cholesterol plaque. This method also makes it possible to distinguish coronary artery disease from other diseases when diagnosis using other methods is difficult or impossible;
  • echocardiography (detection of disturbances in the movement of individual sections of the myocardium);
  • radioisotope diagnostic methods.

  

  To date, electrocardiography seems to be quite affordable, fast and, at the same time, a very informative research method. So, with the help of an ECG, it is possible to detect a macrofocal myocardial infarction (decrease in the R wave, the appearance and deepening of the Q wave, the rise of the ST segment, which takes the characteristic shape of an arc), quite reliably using an ECG. Depression of the ST segment, the appearance of a negative T wave, or the absence of any changes on the cardiogram will manifest subendocardial ischemia with angina pectoris. It should be noted that now even linear ambulance teams are equipped with ECG devices, not to mention specialized ones.

  

  Methods of treatment of various forms of myocardial ischemia

  Currently, there are many different ways to treat coronary heart disease, which can not only prolong the life of the patient, but also significantly improve its quality. These can be conservative (the use of drugs, exercise therapy) and surgical methods (operations that restore the patency of the coronary vessels).

  Proper nutrition

  An important role in the treatment of coronary artery disease and rehabilitation of the patient is played by the normalization of the regimen, the elimination of existing risk factors. It is mandatory to explain to the patient that, for example, smoking can minimize all the efforts of doctors. So, it is important to normalize nutrition: exclude alcohol, fried and fatty foods, foods rich in carbohydrates, in addition, in the presence of obesity, it is necessary to balance the amount and calorie content of the food consumed.

  The diet for coronary disease should be aimed at reducing the consumption of animal fats, increasing the proportion of fiber, vegetable oils in food (vegetables, fruits, fish, seafood). Despite the fact that significant physical activity is contraindicated for such patients, correct and moderate exercise therapy helps to adapt the affected myocardium to the functionality of the vessels that supply it with blood. Hiking, dosed physical exercises under the supervision of a specialist are very useful.

  Medical therapy

  Drug therapy of various forms of coronary artery disease is reduced to the appointment of so-called antianginal drugs that can eliminate or prevent angina attacks. These drugs include:

  

  In all acute forms of coronary artery disease, fast and qualified assistance is needed with the use of effective painkillers, thrombolytics, it may be necessary to administer plasma-substituting drugs (with the development of cardiogenic shock) or defibrillation.

  Operation

  Surgical treatment of cardiac ischemia is reduced to:

  1. restoration of the patency of the coronary arteries (stenting, when a tube is inserted at the site of atherosclerosis of the vessel, preventing further narrowing of its lumen);
  2. or to create a bypass blood supply (coronary artery bypass grafting, mammary coronary bypass grafting).

  With the onset of clinical death, it is very important to start resuscitation measures in time. If the patient's condition worsens, severe shortness of breath appears, heart rhythm disturbances, it is already too late to run to the clinic! Such cases require calling an ambulance, since the patient may need to be hospitalized as soon as possible.

  Video: lecture by a specialist on the treatment of ischemia

  After discharge from the hospital

  Treatment with folk remedies can only be effective in combination with traditional methods. The most common use of various herbs and collections, such as chamomile flowers, motherwort herb, birch leaf tincture, etc. Such infusions and herbal teas can have a diuretic, calming effect, improve blood circulation in various organs. Given the severity of the manifestations, the high risk of death, the use of purely non-traditional means of influence is unacceptable, therefore, it is extremely undesirable to look for any means that can be recommended by ignorant people. Any use of a new medicine or folk remedy should be discussed with the attending physician.

  In addition, when the worst is over, in order to prevent a recurrence, the patient should take for granted the appointment of drugs to correct the lipid composition of the blood plasma. It would be great to dilute drug treatment with physiotherapy procedures, a visit to a psychotherapist and receiving spa treatment.

  Video: coronary heart disease in the program "Live healthy!"

  Tests for hypertension: screening for hypertension

  High blood pressure is a fairly common problem, especially among women and men over 40 years of age. As a disease, high blood pressure manifests itself slowly.

  Symptoms begin with weakness, dizziness, sleep disturbance, fatigue, numbness of the fingers, hot flashes.

  This stage continues for several years in a row, but the patient can ignore it, attributing the symptoms to banal overwork.

  At the next stage, dangerous changes begin in the patient's body that affect the kidneys, heart and brain. If at this time you do not take serious action, do not engage in treatment, high blood pressure will cause dangerous consequences, up to:

  • myocardial infarction;
  • stroke
  • lethal outcome.

  Today, hypertension is detected in many patients, but, unfortunately, it is not customary to take it seriously. According to medical statistics, approximately 40% of people suffer from high blood pressure and this number is steadily increasing.

  Causes and types of hypertension

  There are 2 types of hypertension: essential hypertension, symptomatic arterial hypertension. In the first case, the patient suffers from a chronic disease of the heart and blood vessels.

  The causes of jumps in blood pressure are primarily stress and constant nervous experiences. The more a person is worried, nervous, the higher the risk of increased pressure.

  In addition, hypertension develops in patients with a genetic predisposition to it, especially if more than three close relatives already suffer from hypertension. Subject to timely treatment:

  1. the disease can be controlled;
  2. the likelihood of dangerous complications is significantly reduced.

  It happens that pressure drops occur in an absolutely healthy person. However, at the same time, blood pressure does not reach crisis levels and does not pose any danger to health and life. But it still doesn't hurt to get tested to rule out problems.

  Very often, the cause of high blood pressure is work that requires constant concentration and emotional stress. And people suffer from hypertension:

  • who had previously suffered a concussion;
  • move little;
  • have bad habits.

  If the patient leads a sedentary lifestyle, over time he is diagnosed with atherosclerosis. With severe spasms of blood vessels, the access of blood to vital organs is impaired. When there are plaques on the walls of blood vessels, a strong spasm can provoke a heart attack, a stroke. Therefore, it is necessary to take tests even in order to prevent the disease.

  In women, the causes of problems with pressure will be hormonal changes in the body during menopause.

  Other prerequisites for high blood pressure will be the use of an excessively large amount of kitchen salt, a painful addiction to alcoholic beverages, caffeine, and smoking.

  Not the last role in the formation of pathology is assigned to excess body weight. The more extra pounds, the higher the risk of hypertension.

  What tests need to be done

  Clinical and laboratory examination of the body is used to detect hypertension. First you need to go through an initial appointment with a general practitioner, a cardiologist, who will conduct a visual examination of the patient, study the documentation, medical history.

  After that, tests are required, as they will help confirm hypertension or identify other causes of high blood pressure. It is important to undergo electrocardiography (ECG), the procedure allows you to identify a complication of hypertension, such as myocardial infarction or angina pectoris. To

  In addition to this, an ECG will help determine the current stage of the disease and prescribe adequate therapy.

  Additionally, an ultrasound of the heart is performed, which will establish the presence of:

  • structural anomalies;
  • valve changes;
  • developmental defects.

  For hypertensive patients, it is extremely important to know the degree of left ventricular hypertrophy, the presence or absence of diastolic dysfunction. The study also helps to determine the stage of the pathology of the heart and blood vessels.

  The study of the stiffness of the vascular walls, the degree of their damage by atherosclerosis will help to identify computer sphygmomanometry. The device will estimate the age of the vessels, calculate the probability of cardiovascular accidents, and help adjust the treatment.

  Pulse oximetry is used to measure oxygen saturation in the blood. This examination is necessary to detect the so-called blue heart defects.

  In hypertension, laboratory tests and analyzes are carried out:

  1. urinalysis (protein, density, erythrocytes, glucose);
  2. general clinical blood test (hemoglobin, erythrocytes, leukocyte formula);
  3. biochemical blood test (creatinine, potassium, calcium, uric acid, cholesterol, glucose).

  These biochemical indicators are necessary to determine the exact cause of high blood pressure, the degree of damage to target organs, control the safety of medicines, and track the dynamics of the disease.

  Features of the ECG

  Electrocardiography is a method of recording currents that occur in the heart. Taking electrocardiogram data is a fairly simple procedure, so such analyzes are done in any medical institution, ambulance, or even at home.

  The main indicators to evaluate the ECG:

  1. functions of the leading system;
  2. determination of the rhythm of cardiac activity;
  3. diagnosis of the degree of enlargement of the heart;
  4. assessment of the state of coronary blood supply;
  5. identification of damage to the heart muscle, its depth and time of occurrence.

  With an increase in blood pressure, the contractile functions of the heart on the ECG will be visible only indirectly.

  For the procedure, the patient must undress to the waist and expose the shins. Ideally, in case of hypertension, the study is carried out no earlier than 2 hours after a meal and after 15 minutes of rest. An electrocardiogram is recorded when the patient is in a horizontal position.

  To obtain data, napkins soaked in water are applied to the lower part of the legs and forearms, and metal plates of electrodes are placed on top of them. The places where the electrodes are applied are preliminarily degreased with alcohol. This procedure helps to improve the quality of the ECG, reduce the amount of inductive currents.

  The examination is carried out with calm breathing, and at least 4 cardiac cycles are noted in each branch. In case of hypertension, the electrodes are applied in a certain order, and each of them has its own color:

  • red - right hand;
  • yellow - left hand;
  • green - left leg;
  • black - right leg.

  The ECG consists of intervals and teeth, that is, the spaces between the teeth. During the decoding of the cardiogram of hypertension, the doctor will evaluate the shape, size of each of the teeth, intervals. You will need to establish stability, repeat accuracy.

  It should be said that this examination with high blood pressure has a number of disadvantages. So, the diagnosis is short-term and is not able to fix pathologies with an unstable cardiographic picture. When the violation is temporary and does not make itself felt when recording an ECG, it will not be possible to identify it.

  An electrocardiogram will not display cardiac hemodynamics, will not show the presence of heart murmurs, malformations. To diagnose these pathological conditions, you will need to undergo an additional ultrasound examination (ultrasound).

  Despite the high value of the data, it is necessary to carry out the assessment with the obligatory consideration of all clinical indicators, since different pathological processes can have many similar changes.

  How to prepare for the procedure

  Despite the statement that it is not necessary to prepare for an electrocardiography, experienced doctors strongly recommend taking the procedure seriously. The essence of the manipulation is to assess the work of the heart muscle under normal conditions. For this reason, it is extremely important before the cardiogram:

  • do not be nervous;
  • not experience fatigue;
  • sleep well;
  • give up physical activity.

  In addition, you can not overload the digestive tract, it is best to undergo diagnostics on an empty stomach. If the procedure is carried out after a hearty lunch, the data may not be accurate.

  Another recommendation - in the presence of high blood pressure and hypertension on the day of the study, you should stop drinking large amounts of liquid. An excess of water will negatively affect the work of the heart muscle.

  It is strictly forbidden to use natural coffee, strong black tea, energy drinks on the day of manipulation, since caffeine quickly stimulates an increase in cardiac activity. As a result, the analyzes will be biased and will need to be repeated.

  In the morning, before the electrocardiogram, it is shown to take a shower, but without hygiene products. Gels and soaps will create an oil film on the surface of the skin, which seriously impairs the contact of the electrodes with the integument of hypertensive patients.

  With a constant increase in blood pressure and hypertension, there is a high risk of damage to important organs, and first of all:

  • kidneys;
  • liver;
  • hearts;
  • brain.

  Such problems can be fatal if the patient, with an increase in blood pressure, ignores treatment, does not fully comply with the doctor's instructions, and does not pass the necessary tests.

  Speaking of the heart, diseases most often develop: ischemia, atherosclerosis, angina pectoris, myocardial infarction.

  It should be noted that prolonged high blood pressure can cause heart failure, diffuse cardiosclerosis. Terrible complications of the pathology will be severe damage to the brain, kidneys. At the heart of the disease is progressive vasoconstriction, a constant increase in blood pressure.

  With hypertension, irreversible sclerotic changes in the kidneys take place, when the so-called wrinkled kidneys form. The organs cannot perform their functions normally, the patient suffers from chronic renal failure of varying degrees.

  If there is no control of blood pressure, the patient does not pass the necessary tests:

  • early organ damage occurs;
  • without the ability to compensate for their functions.

  Prevention

  Whatever the blood pressure, it must always be controlled. To prevent hypertension and arterial hypertension, regular physical activity is shown, which will help maintain blood vessels in good shape.

  The patient needs to completely stop smoking, which provokes narrowing of blood vessels. To avoid overvoltage and jumps in blood pressure, it is recommended to follow the daily routine, correctly alternating work and rest.

  When a person's labor activity is associated with excessive physical exertion, the patient needs to rest in a calm environment.

  It is important to periodically:

  1. take blood tests for sugar levels;
  2. measure blood pressure;
  3. do an ECG of the heart.

  Blood pressure measurements and an electrocardiogram can now be carried out simply at home. This will allow you to monitor the slightest changes in the body and identify the development of dangerous diseases, including hypertension. The educational video in this article will help you understand what to do for and against hypertension.

  on the

  Medical treatment of angina pectoris

  Angina pectoris is a form of coronary heart disease that occurs when there is insufficient blood supply to the heart. The cause of the manifestation of alarming symptoms of the disease is more often atherosclerosis of the vessels - plaques narrow the lumen of the arteries, preventing their reflex expansion. Angina pectoris manifests itself in the form of discomfort behind the sternum - pain, squeezing, pressure, burning, heaviness. Attacks lasting 1-5 minutes are noted by the patient during any physical exertion and emotional stress.

  About 80% of patients who seek help from a cardiologist are men aged 50-60.

  Do not turn a blind eye to alarming symptoms - consult a doctor! After examining and questioning the patient, after passing the necessary tests, the specialist will make a diagnosis and prescribe the appropriate treatment. And therapy is impossible if you do not take special drugs for the treatment of angina pectoris - antianginal drugs. The drug approach will help the body cope with increased stress, normalize blood pressure, lower cholesterol and blood viscosity.

  

  Be patient - the treatment will be long. Sometimes patients are forced to "sit" on drugs for life in order to maintain good health and not bring the course of the disease to myocardial infarction.

  Features of prescribing drugs

  There is no "universal" drug for angina pectoris - each patient must be examined individually. When prescribing drugs, a cardiologist takes into account the patient's age, general health, risk factors for complications of heart disease, and the results of tests and tests. And if the remedy is suitable for one patient, this does not mean that it is suitable for another - the disease can proceed in different ways.

  There are 2 approaches that doctors use when prescribing certain drugs to a patient. It is important for a specialist to establish which of the drugs is most effective in a particular case. The approaches are:

  1. The purpose of drugs is based on the characteristics of the course and clinical symptoms of angina pectoris. The functional class of the patient is also taken into account. This means that in a patient of the 2nd functional class, therapy takes place only with one of the types of drugs - nitrates, calcium antagonists, b-blockers. But the severe form of angina pectoris will be accompanied by treatment with the appointment of drugs of various mechanisms of action.
  2. The purpose of drugs is based on a clear assessment of their pharmacodynamic efficacy in relation to a particular patient. In rare cases, specialists conduct studies to determine how well certain drugs are absorbed by the patient's body. In practice, another technique is more often used - a test on a bicycle ergometer. This is a dosed physical activity for a patient with stable angina pectoris using a special exercise bike. Stable work of the heart during tests on a bicycle ergometer against the background of treatment with selected medications indicates the effectiveness of the selected medication.

  In each of the cases, individual intolerance to a particular drug, the patient's allergy to individual components of the funds, must be taken into account.

  Cardiologists advise patients with newly diagnosed angina to keep a diary. In it, you need to mark each attack and the pills taken to relieve it. The doctor in the future, evaluating the patient's records, will make a more complete anamnesis, which will help to make the correct diagnosis and prescribe the necessary drugs.

  Nitrates for the treatment of angina pectoris

  Nitrates are effective antianginal drugs often used to treat angina pectoris and coronary artery disease. They relieve tension in the walls of blood vessels, reduce the need for oxygen in the heart, and increase blood flow in the collaterals. The pharmacological activity of nitrates increases if the active components enter the body through the mucous membranes.

  

  List of nitrates commonly prescribed by a doctor:

  1. Nitroglycerin (tablets, ointments, patches). One of the most effective means taken by the patient for the relief of acute attacks of angina pectoris and as a preventive measure (before physical exertion). Tablets are taken under the tongue, thereby providing a quick effect - the pain recedes. But ointments and patches, as practice shows, are not so practical - with a low concentration of nitroglycerin, the positive effect is noticeably small. If you follow the doctor's instructions, taking the right dose of nitroglycerin, the medicine will not cause any side effects - severe hypotension and headaches.
  2. Isosorbide dinitrate (isomak, isosorb retard, nitrosorbide). The drug begins to act 10-20 minutes after administration. The tablet is placed under the tongue or chewed. In pharmacies, you can find medicine in the form of an aerosol - 1 dose injected into the mucous membrane corresponds to 1.25 mg of the active substance. The drug begins to "work" 2-5 minutes after use.
  3. Isosorbide-5-mononitrate - modern drugs that can be taken once a day to prevent an attack.

  β-blockers for the treatment of angina pectoris

  The doctor prescribes drugs of this class to reduce the need for myocardial oxygen supply. The action of β-blockers is based on the normalization of heart rate and myocardial contractility. Medicines are effective for angina pectoris observed due to physical exertion. At rest, they slightly reduce the pulse rate and pressure.

  β-blockers often used for exertional angina are atenolol, metoprolol, bisoprolol (Concor). Taking drugs begins with small doses - it is important to identify side effects. With good tolerance, the daily dose, on the recommendation of a doctor, can be increased.

  Modern beta-blockers are largely devoid of side effects due to their selectivity - they act only on the heart.

  Calcium channel blockers for the treatment of angina pectoris

  Medications are aimed at blocking L-type calcium channels - they are the most significant for the heart and blood vessels. As a result of the reception, the heart rate is significantly reduced, the vessels expand.

  Effective calcium channel blockers are verapamil, nifedipine, diltiazem. As an antianginal agent, doctors often prescribe verapamil to patients (more effective in vasospastic angina pectoris). Each of the drugs can be combined with nitrates and adrenoblockers.

  But in such cases, careful selection of doses is needed - so that the patient's condition does not worsen, it is important to take into account the existing symptoms and other complications. For example, the use of calcium channel blockers in combination with nitrates against the background of angina pectoris and left ventricular dysfunction can lead to heart failure.

  Antiplatelet agents for the treatment of angina pectoris

  Antiplatelet agents prevent the formation of blood clots, dilate the coronary vessels, increase the volumetric velocity of blood flow through the heart vessels. There are 3 groups of drugs of this class:

  • cyclooxygenase inhibitors (aspirin);
  • platelet inhibitors (dipyridamole);
  • adenosine receptor inhibitors (clopidogrel, ticlopidine).

  Effective drugs for the prevention of heart attacks and strokes are aspirin and clopidogrel. Acetylsalicylic acid in small doses prevents thrombosis without harming the stomach. Tablets act 15 minutes after administration. In pharmacies, there are many drugs based on aspirin - a different name, but the essence is the same. Clopidogrel is often prescribed in combination with aspirin. But if the doctor has planned a coronary bypass, the remedy is canceled.

  Statins for the treatment of angina pectoris

  Statins lower bad cholesterol levels in the blood. It is noticed that if you take drugs for a long time, atherosclerotic plaques can even decrease in size. There is no addiction to drugs of this class, so patients take them throughout the course of drug therapy.

  Cholesterol levels after the appointment of statins must be monitored - 2-4 times a year, donate blood for analysis.

  There are not many drugs of this class in pharmacies - Zocor, Leskol, Liprimar, Crestor. Tablets are taken at bedtime. Side effects include muscle pain, nausea, and stool disorders. Statins should not be taken by patients with diagnosed liver disease, pregnant or lactating women.

  Dosage of drugs

  Doses of medicines are prescribed only by a doctor! Antianginal drugs have a strong effect, which, if taken incorrectly, will affect the patient's health. And despite the fact that in the package for all tablets there is an instruction with dosages, consult a cardiologist before using them.

  

  Any self-activity is dangerous! The sudden cancellation of the prescribed medication, a decrease or increase in the dose will lead to a deterioration in the patient's well-being and the development of myocardial infarction.

  Without what medical treatment is impossible?

  Ischemic heart disease can accompany the patient all his life. And to prevent complications, treatment should be as complete as possible! But pills alone are not enough for therapy - reconsider your lifestyle.

  Medications will only slow down the development of complex heart pathologies. To normalize its work and not end up on the operating table, an integrated approach is needed:

  1. Proper nutrition - less flour, fried, canned.
  2. Refusal of bad habits - smoking and alcohol.
  3. Constant monitoring of the level of pressure, sugar and cholesterol in the blood.
  4. Dosed physical activity.

  The medications prescribed by the doctor and adherence to the regimen will help to avoid further complications associated with a heart attack.

  Ministry of Health of the Republic of Belarus Republican Scientific and Practical Center "Cardiology" Belarusian Scientific Society of Cardiology

  DIAGNOSIS AND TREATMENT

  and "Myocardial Revascularization" (European Society of Cardiology and European Association of Cardiothoracic Surgeons, 2010)

  Prof., Corresponding Member NAS RB N.A. Manak (RSPC "Cardiology", Minsk) MD E.S. Atroshchenko (RSPC "Cardiology", Minsk)

  PhD I.S. Karpova (RSPC "Cardiology", Minsk) Ph.D. IN AND. Stelmashok (RSPC "Cardiology", Minsk)

  Minsk, 2010

  1. INTRODUCTION............................................... ................................................. ...............
  2. DEFINITION AND CAUSES OF ANGINA .............................................................. .........
  3. CLASSIFICATION OF ANGINA.................................................................... .........................
  3.1. Spontaneous angina .............................................................. ................................................. ..........
  3.2. Variant angina .............................................................. ................................................. ..........
  3.3. Painless (silent) myocardial ischemia (MIA) .............................................................. ......................
  3.4. Cardiac syndrome X (microvascular angina) ....................................................
  4. EXAMPLES OF FORMULATION OF THE DIAGNOSIS .............................................. ............
  5. DIAGNOSIS OF ANGINA .............................................................. ......................
  5.1. Physical examination .................................................................. ................................................. ...
  5.2. Laboratory research................................................ ................................................. .
  5.3. Instrumental diagnostics .................................................................. ...............................................
  5.3.1. Electrocardiography .................................................................. ................................................. ..........
  5.3.2. Exercise tests ............................................................... ...............................................
  5.3.3. 24-hour ECG monitoring ............................................................... .........................................
  5.3.4. Chest X-ray .............................................................................. .........................
  5.3.5. Transesophageal atrial electrical stimulation (TEPS) .............................................
  5.3.6. Pharmacological tests .................................................................. ................................................. ...
  5.3.7. Echocardiography (EchoCG) ............................................... ................................................. ......
  5.3.8. Myocardial perfusion scintigraphy with loading .............................................................. ...
  5.3.9. Positron emission tomography (PET) .............................................................. .................
  5.3.10. Multislice computed tomography (MSCT)
  heart and coronary vessels ....................................................... .................................................
  5.4. Invasive research methods .............................................................. ................................................
  5.4.1. Coronary angiography (CAG) ............................................... ...............................................
  5.4.2. Intravascular ultrasound examination of the coronary arteries........
  5.5. Differential diagnosis of chest pain syndrome
  6. FEATURES OF DIAGNOSTICS OF STABLE
  ANGINA IN SELECTED GROUPS OF PATIENTS
  AND WITH CONCOMITANT DISEASES .............................................................. ...........
  6.1. Ischemic heart disease in women .............................................................. ...............................
  6.2. Angina pectoris in the elderly ....................................................... ................................................. .............
  6.3. Angina pectoris in arterial hypertension .............................................................. ...................
  6.4. Angina pectoris in diabetes mellitus .............................................. ...............................................

  7. TREATMENT OF CHD....................................................... ................................................. ........
  7.1. Goals and tactics of treatment ............................................... ................................................. ...............
  7.2. Non-pharmacological treatment of angina pectoris ............................................................... .......................
  7.3. Medical treatment of angina .............................................................. ...............................
  7.3.1. Antiplatelet drugs
  (acetylsalicylic acid, clopidogrel) .............................................. ...............................
  7.3.2. Beta-blockers ............................................................... ................................................. ...........
  7.3.3. Lipid normalizers .................................................................. .........................................
  7.3.4. ACE inhibitors .................................................................. ................................................. ......................
  7.3.5. Anti-anginal (anti-ischemic) therapy .............................................. ...............
  7.4. Criteria for the effectiveness of treatment .................................................................... .........................................
  8. CORONARY REVASCULARIZATION .............................................................. .................
  8.1. Coronary angioplasty .............................................................. ................................................. .....
  8.2. Coronary artery bypass .................................................................. ................................................. .....
  8.3. Principles of management of patients after PCI ..........................................................
  9. REHABILITATION OF PATIENTS WITH STABLE ANGINA..........................
  9.1. Improving lifestyle and correcting risk factors ..............................................
  9.2. Physical activity................................................ ................................................. .............
  9.3. Psychological rehabilitation .................................................................. ...............................................
  9.4. The sexual aspect of rehabilitation .............................................................. ................................................
  10. WORKABILITY ............................................................... ................................................
  11. DISPENSARY SUPERVISION ............................................................... .........................
  ATTACHMENT 1 ................................................ ................................................. ....................................
  APPENDIX 2 .................................................. ................................................. ....................................
  APPENDIX 3 .................................................. ................................................. ....................................

  List of abbreviations and symbols used in recommendations

  AH - arterial hypertension

  BP - blood pressure

  AK - calcium antagonists

  CABG - coronary artery bypass grafting

  ACE - angiotensin converting enzyme

  ASA - acetylsalicylic acid

  BB - beta-blockers

  SIMI - painless (silent) myocardial ischemia

  CVD - disease of the circulatory system

  WHO - World Health Organization

  BC - sudden death

  VEM - bicycle ergometric test

  HCM - hypertrophic cardiomyopathy

  LVH - left ventricular hypertrophy

  HRH - right ventricular hypertrophy

  DBP - diastolic blood pressure

  DCM - dilated cardiomyopathy

  DP - double product

  DFT - dosed physical training

  IA - atherogenicity index

  IHD - ischemic heart disease

  ID - isosorbide dinitrate

  MI - myocardial infarction

  IMN - isosorbide mononitrate

  CA - coronary arteries

  CAG - coronary angiography

  QOL - quality of life

  KIAP - cooperative study of antianginal drugs

  CABG - coronary artery bypass grafting

  Minsk, 2010

  HDL - high density lipoproteins

  LV - left ventricle

  LDL - low density lipoproteins

  VLDL - very low density lipoproteins

  Lp - lipoprotein

  MET - metabolic unit

  MSCT - multislice computed tomography

  MT - drug therapy

  NG - nitroglycerin

  IGT - Impaired Glucose Tolerance

  FROM / OB - waist / hips

  PET - Positron Emission Tomography

  RFP - radiopharmaceutical

  SBP - systolic blood pressure

  DM - diabetes mellitus

  CM - daily monitoring

  CVD - cardiovascular diseases

  CCH - stable exertional angina

  TG - triglycerides

  EF - ejection fraction

  FK - functional class

  RF - risk factor

  COPD - chronic obstructive pulmonary disease

  CS - total cholesterol

  TEAS - transesophageal atrial electrical stimulation

  HR - heart rate

  PTCA - percutaneous coronary artery plasty

  ECG - electrocardiography

  EchoCG - echocardiography

  1. INTRODUCTION

  AT The Republic of Belarus, as in all countries of the world, is experiencing an increase in the incidence of diseases of the circulatory system (CVD), which traditionally occupy the first place in the structure of mortality and disability of the population. Thus, in 2009, compared with 2008, there was an increase in the overall incidence of CSD from 2762.6 to 2933.3 (+6.2%) per 10,000 adults. In the structure of CSD, there is an increase in the level of acute and chronic forms of coronary heart disease (CHD): the total incidence of CHD in 2009 was 1215.3 per 10 thousand of the adult population (in 2008 - 1125.0; 2007 - 990.6).

  AT In 2009, there was an increase in the proportion of mortality from CSD up to 54% (2008 - 52.7%) due to an increase in mortality from chronic coronary artery disease by 1.3% (2008 - 62.5%, 2009 - 63, eight%). In the structure of the primary access to disability of the population of the Republic of Belarus, the CSCs in 2009 amounted to 28.1% (in 2008 - 28.3%); mostly patients with coronary artery disease.

  The most common form of CAD is angina pectoris. According to the European Society of Cardiology in countries with a high level of coronary artery disease, the number of patients with angina pectoris is 30,000 - 40,000 per 1 million population. Approximately 22,000 new cases of angina per year are expected in the Belarusian population. In general, in the republic there is an increase in the incidence of angina pectoris by 11.9% compared to 2008. (2008 - 289.2; 2009 - 304.9).

  According to the Framingham study, exertional angina is the first symptom of coronary artery disease in men in 40.7% of cases, in women - in 56.5%. The frequency of angina pectoris increases sharply with age: in women from 0.1-1% at the age of 45-54 years to 10-15% at the age of 65-74 years and in men from 2-5% at the age of 45-54 years to 10- 20% aged 65-74 years.

  The average annual mortality among patients with angina pectoris averages 2-4%. Patients diagnosed with stable angina pectoris die from acute forms of coronary artery disease 2 times more often than those without this disease. According to the results of the Framingham study, in patients with stable angina, the risk of developing non-fatal myocardial infarction and death from coronary artery disease within 2 years is respectively: 14.3% and 5.5% in men and 6.2% and 3.8% in women.

  Minsk, 2010

  

  Diagnosis and treatment of stable angina pectoris

  		Reliable evidence and/or unanimity of expert opinion
  		that the procedure or treatment is appropriate
  		different, useful and effective.
  		Contradictory data and / or divergence of expert opinions
  		about the benefits/effectiveness of procedures and treatments
  		Dominant evidence and/or expert opinion on the use of
  		ze / effectiveness of therapeutic effects.
  		Benefits/effectiveness not well established
  		evidence and/or expert opinion.
  		The available data or the general opinion of experts is evidence
  		feel that the treatment is not useful/effective
  		and in some cases can be harmful.

  * Class III application not recommended

  AT In accordance with the presented classification principles, the confidence levels are as follows:

  Levels of Evidence

  Results of numerous randomized clinical trials or meta-analysis.

  Results of one randomized clinical trial or large non-randomized trials.

  General opinion of experts and/or results of small studies, retrospective studies, registers.

  2. DEFINITION AND CAUSES OF ANGINA

  Angina pectoris is a clinical syndrome manifested by a feeling of discomfort or pain in the chest of a compressive, pressing nature, which is most often localized behind the sternum and can radiate to the left arm, neck, lower jaw, epigastric region, left shoulder blade.

  The pathomorphological substrate of angina pectoris is almost always atherosclerotic narrowing of the coronary arteries. Angina pectoris appears during physical exertion (PE) or stressful situations, in the presence of a narrowing of the lumen of the coronary artery, as a rule, by at least 50-70%. In rare cases, angina pectoris can develop in the absence of visible stenosis in the coronary arteries, but in such cases, angiospasm or dysfunction of the coronary endothelium almost always occurs. Sometimes angina can develop

  with pathological conditions of various nature: valvular heart disease (stenosis of the aortic orifice or aortic valve insufficiency, mitral valve disease), arterial hypertension, syphilitic aortitis; inflammatory or allergic vascular diseases (periarteritis nodosa, thromboangiitis, systemic lupus erythematosus), mechanical compression of the coronary vessels, for example, due to the development of scars or infiltrative processes in the heart muscle (with injuries, neoplasms, lymphomas, etc.), a number of metabolic changes in myocardium, for example, with hyperthyroidism, hypokalemia; in the presence of foci of pathological impulses from one or another internal organ (stomach, gallbladder, etc.); with lesions of the pituitary-diencephalic region; with anemia, etc.

  In all cases, angina pectoris is caused by transient myocardial ischemia, which is based on a mismatch between myocardial oxygen demand and its delivery by the coronary blood flow.

  The formation of atherosclerotic plaque occurs in several stages. With the accumulation of lipids in the plaque, ruptures of its fibrous cover occur, which is accompanied by the deposition of platelet aggregates that contribute to the local deposition of fibrin. The location area of ​​the parietal thrombus is covered with newly formed endothelium and protrudes into the lumen of the vessel, narrowing it. Along with lipid fibrous plaques, fibrous stenosing plaques are also formed, which undergo calcification. At present, there is enough data to state that the pathogenesis of atherosclerosis is equally associated with both the pathological effect of modified LDL on the vascular wall and the immune inflammation reactions that develop in the vascular wall. V.A. Nagornev and E.G. Zota consider atherosclerosis as a chronic aseptic inflammation, in which periods of exacerbation of atherosclerosis alternate with periods of remission. Inflammation underlies the destabilization of atherosclerotic plaques.

  As each plaque develops and grows in size, the degree of stenosis of the lumen of the coronary arteries increases, which largely determines the severity of clinical manifestations and the course of IHD. The more proximal the stenosis is located, the greater the mass of the myocardium undergoes ischemia in accordance with the zone of vascularization. The most severe manifestations of myocardial ischemia are observed with stenosis of the main trunk or mouth of the left coronary artery. The severity of manifestations of coronary artery disease may be greater than the expected degree of atherosclerotic stenosis of the coronary artery, respectively. Such

  Minsk, 2010

  Diagnosis and treatment of stable angina pectoris

  cases in the origin of myocardial ischemia, a sharp increase in its oxygen demand, coronary angiospasm or thrombosis, which sometimes acquire a leading role in the pathogenesis of coronary insufficiency, can play a role. The prerequisites for thrombosis due to damage to the endothelium of the vascular a may occur already in the early stages of the development of an atherosclerotic plaque. In this, the processes of hemostasis disorders, primarily platelet activation and endothelial dysfunction, play a significant role. Platelet adhesion, firstly, is the initial link in the formation of a thrombus when the endothelium is damaged or the capsule of an atherosclerotic plaque is torn; secondly, it releases a number of vasoactive compounds, such as thromboxane A2, platelet growth factor, etc. Platelet microthrombosis and microembolism can aggravate blood flow disorders in a stenotic vessel. It is believed that at the level of microvessels, the maintenance of normal blood flow is largely dependent on the balance between thromboxane A2 and prostacyclin.

  In rare cases, angina pectoris can develop in the absence of visible stenosis in the coronary arteries, but in such cases, angiospasm or dysfunction of the coronary endothelium almost always occurs.

  Chest pain, similar to angina pectoris, can occur not only with certain cardiovascular diseases (CVD) (except for IHD), but also with diseases of the lungs, esophagus, musculoskeletal and nervous apparatus of the chest, and diaphragm. In rare cases, chest pain radiates from the abdominal cavity (see section "Differential Diagnosis of Chest Pain Syndrome").

  3. CLASSIFICATION OF ANGINA

  Stable exertional angina (SCH) is pain attacks that last more than one month, have a certain frequency, occur with approximately the same physical exertion.

  and treated with nitroglycerin.

  AT International Classification of Diseases X revision stable coronary artery disease is in 2 headings.

  I25 Chronic ischemic heart disease

  I25.6 Asymptomatic myocardial ischemia

  I25.8 Other forms of ischemic heart disease

  I20 Angina pectoris [angina pectoris]

  I20.1 Angina pectoris with documented spasm

  I20.8 Other angina pectoris

  

  In clinical practice, it is more convenient to use the WHO classification, since it takes into account different forms of the disease. In official medical statistics, ICD-10 is used.

  Classification of stable angina

  1. Angina pectoris:

  1.1. first-time angina pectoris.

  1.2. stable exertional angina with indication of FC(I-IV).

  1.3. spontaneous angina (vasospastic, special, variant, Prinzmetal).

  AT In recent years, due to the widespread introduction of objective examination methods (stress tests, daily ECG monitoring, myocardial perfusion scintigraphy, coronary angiography), such forms of chronic coronary insufficiency as painless myocardial ischemia and cardiac syndrome X (microvascular angina pectoris) have begun to be distinguished.

  First-time angina pectoris - duration up to 1 month from the moment of occurrence. Stable angina - duration more than 1 month.

  Table 1 FC severity of stable exertional angina according to the classification

  Canadian Association of Cardiology (L. Campeau, 1976)

  		signs
  		"Ordinary daily physical activity" (walking or
  		climbing stairs) does not cause angina pectoris. Pains arise
  		only when doing very intense, or very fast,
  		or prolonged FN.
  		"Slight restriction of usual physical activity",
  		what does angina pectoris mean when walking fast
  		or climbing stairs, after eating, or in the cold, or in the wind
  		weather, or with emotional stress, or in per-
  		a few hours after waking up; while walking on
  		more than 200 m (two blocks) on level ground
  		or while climbing stairs more than one flight in
  		normal pace under normal conditions.

  "Significant limitation of usual physical activity"

  - angina pectoris occurs as a result of calm walking on the

  III standing one to two blocks(100-200 m) on level ground or climbing one flight of stairs at a normal pace under normal conditions.

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