Modern methods of treatment of coronary heart disease. Drugs for the treatment of coronary heart disease. Metabolic drugs

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

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

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

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

Treatment regimens for patients with angina pectoris

Standard of emergency care for angina pectoris.

1. With an anginal attack:

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

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

Physical and emotional peace;

Correction of blood pressure and heart rate.

2. With a persistent attack of angina pectoris:

oxygen therapy;

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

heparin 10,000 IU IV;

give to chew 0.25 g acetylsalicylic acid .

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

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

4. With ventricular extrasystoles of the 3rd-5th gradation:

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

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

Management strategy for patients with ACS .

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Antithrombotic drugs.

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

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

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

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

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

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

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

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

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

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

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

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

Cytoprotective drugs.

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

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

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

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

Coronaroplasty.

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

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

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

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

Indications for percutaneous and surgical interventions.

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

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

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

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

Ischemic (coronary) heart disease (CHD), which develops as a result of atherosclerosis of the coronary arteries, is the leading cause of disability and mortality in the working population worldwide. In Russia, the prevalence of cardiovascular diseases and ischemic heart disease is growing, and in terms of mortality from them, our country is one of the first places in the world, which necessitates the use of modern and effective methods of their treatment and prevention by doctors. Among the population of Russia, a high prevalence of the main risk factors for the development of coronary artery disease remains, of which highest value have smoking, arterial hypertension, hypercholesterolemia.

Atherosclerosis is the main cause of coronary artery disease. It flows in secret long time until it leads to complications such as myocardial infarction, cerebral stroke, sudden death, or to the appearance of angina pectoris, chronic cerebrovascular insufficiency, to intermittent claudication. Atherosclerosis leads to gradual local stenosis of the coronary, cerebral and other arteries due to the formation and growth of atherosclerotic plaques in them. In addition, such factors as endothelial dysfunction, regional spasms, impaired microcirculation, as well as the presence of a primary inflammatory process in vascular wall as a possible factor in the formation of thrombosis. An imbalance of vasodilatory and vasoconstrictor stimuli can also significantly change the state of coronary artery tone, creating an additional dynamic stenosis to the already existing fixed one.

The development of stable angina can be predictable, for example, in the presence of factors that cause an increase in myocardial oxygen demand, such as physical or emotional stress (stress).

Patients with angina pectoris, including those who have already had myocardial infarction, constitute the largest group of patients with coronary artery disease. This explains the interest of practitioners in the proper management of patients with angina pectoris and the choice of optimal methods of treatment.

Clinical forms of coronary artery disease. IHD manifests itself in many clinical forms: chronic stable angina, unstable (progressive) angina, asymptomatic coronary artery disease, vasospastic angina, myocardial infarction, heart failure, sudden death. Transient myocardial ischemia, usually resulting from narrowing of the coronary arteries and increased oxygen demand, is the main mechanism for the onset of stable angina.

Chronic stable angina is usually divided into 4 functional classes according to the severity of symptoms (Canadian classification).

The main goals of treatment are to improve the patient's quality of life by reducing the frequency of angina attacks, preventing acute myocardial infarction, and improving survival. Successful antianginal treatment is considered in the case of complete or almost complete elimination of angina attacks and the return of the patient to normal activity (angina pectoris is not higher than functional class I, when pain attacks occur only with significant stress) and with minimal side effects of therapy.

In the treatment of chronic coronary artery disease, 3 main groups of drugs are used: β-blockers, calcium antagonists, organic nitrates, which significantly reduce the number of angina attacks, reduce the need for nitroglycerin, increase exercise tolerance and improve the quality of life of patients.

However, practitioners are still reluctant to prescribe new effective drugs in sufficient doses. In addition, in the presence of a large selection of modern antianginal and anti-ischemic drugs, obsolete, insufficiently effective ones should be excluded. A frank conversation with the patient, an explanation of the cause of the disease and its complications, the need for additional non-invasive and invasive research methods helps to choose the right method of treatment.

According to the results of the ATP-survey study (Angina Treatment Patterns), in Russia, when choosing antianginal drugs with a hemodynamic mechanism of action in monotherapy mode, preference is given to nitrates (11.9%), then b-blockers (7.8%) and calcium antagonists (2 .7%).

β-blockers are the drugs of first choice for the treatment of patients with angina, especially in patients who have had myocardial infarction, as they lead to a decrease in mortality and the incidence of re-infarction. The drugs of this group have been used in the treatment of patients with coronary artery disease for more than 40 years.

β-blockers cause an antianginal effect by reducing myocardial oxygen demand (due to a decrease in heart rate, lowering blood pressure and contractility myocardium), increased delivery of oxygen to the myocardium (due to increased collateral blood flow, its redistribution in favor of the ischemic layers of the myocardium - subendocardium), antiarrhythmic and antiaggregatory effects, and a decrease in calcium accumulation in ischemic cardiomyocytes.

Indications for the use of β-blockers are the presence of angina pectoris, angina pectoris with concomitant arterial hypertension, concomitant heart failure, "silent" myocardial ischemia, myocardial ischemia with comorbidities rhythm. In the absence of direct contraindications, β-blockers are prescribed to all patients with coronary artery disease especially after myocardial infarction. The goal of therapy is to improve distant forecast a patient with IBS.

Among β-blockers propranolol (80-320 mg/day), atenolol (25-100 mg/day), metoprolol (50-200 mg/day), carvedilol (25-50 mg/day), bisoprolol (5 - 20 mg/day), nebivolol (5 mg/day). Drugs with cardioselectivity (atenolol, metoprolol, betaxolol) have a predominantly blocking effect on β 1 -adrenergic receptors.

One of the most widely used cardioselective drugs is atenolol (tenormin). The initial dose is 50 mg / day. In the future, it can be increased to 200 mg / day. The drug is prescribed once in the morning. With severe renal impairment, the daily dose should be reduced.

Another cardioselective β-blocker is metoprolol (Betaloc). Its daily dose averages 100-300 mg, the drug is prescribed in 2 doses, since the β-blocking effect can be traced up to 12 hours. At present, prolonged metoprolol preparations - betalok ZOK, metocard, the duration of the effect of which reaches 24 hours.

Bisoprolol (Concor) in comparison with atenolol and metoprolol has a more pronounced cardioselectivity (in therapeutic doses it blocks only β 1 -adrenergic receptors) and a longer duration of action. It is used once a day at a dose of 2.5-20 mg.

Carvedilol (Dilatrend) has a combined non-selective β-, α 1 -blocking and antioxidant effect. The drug blocks both β 1 - and β 2 -adrenergic receptors, without its own sympathomimetic activity. Due to the blockade of α 1 -adrenergic receptors located in the smooth muscle cells of the vascular wall, carvedilol causes pronounced vasodilation. Thus, it combines β-blocking and vasodilatory activity, which is mainly due to its antianginal and anti-ischemic effect, which persists with long-term use. Carvedilol also has a hypotensive effect and inhibits the proliferation of smooth muscle cells, which plays a proatherogenic role. The drug is able to reduce the viscosity of blood plasma, aggregation of red blood cells and platelets. In patients with impaired left ventricular (LV) function or circulatory failure, carvedilol favorably affects hemodynamic parameters (reduces pre- and afterload), increases ejection fraction and reduces LV size. Thus, the appointment of carvedilol is indicated primarily for patients with coronary artery disease, myocardial infarction, with heart failure, since in this group of patients its ability to significantly improve the prognosis of the disease and increase life expectancy has been proven. When comparing carvedilol (mean daily dose 20.5 mg) and atenolol (mean daily dose 25.9 mg), it was shown that both drugs, administered 2 times a day, are equally effective in the treatment of patients with stable exertional angina. One of the guidelines for the adequacy of the used dose of β-blockers is the reduction in heart rate at rest to 55-60 beats / min. In some cases, in patients with severe angina, resting heart rate may be reduced to less than 50 beats / min.

Nebivolol (nebilet) is a new selective β 1 -blocker that also stimulates the synthesis of nitric oxide (NO). The drug causes hemodynamic unloading of the heart: reduces blood pressure, pre- and afterload, increases cardiac output, increases peripheral blood flow. Nebivolol is a b-blocker with unique properties, which consist in the ability of the drug to participate in the process of synthesis of the relaxing factor (NO) by endothelial cells. This property gives the drug an additional vasodilating effect. The drug is used primarily in patients with arterial hypertension with angina attacks.

Celiprolol (200-600 mg/day), a third-generation β-blocker, differs from other β-blockers in its high selectivity, moderate stimulation of β2-adrenergic receptors, direct vasodilating effect on blood vessels, modulation of nitric oxide release from endothelial cells, and the absence of adverse metabolic effects . The drug is recommended for patients with coronary artery disease with chronic obstructive pulmonary disease, dyslipidemia, diabetes mellitus, peripheral vascular disease caused by tobacco smoking. Celiprolol (200-600 mg/day), atenolol (50-100 mg/day), propranolol (80-320 mg/day) have comparable antianginal efficacy and equally increase exercise tolerance in patients with stable exertional angina.

β-blockers should be given preference, appointing patients with coronary heart disease in the presence of a clear relationship between physical activity and the development of an angina attack, with concomitant arterial hypertension; the presence of rhythm disturbances (supraventricular or ventricular arrhythmias), with myocardial infarction myocardium, expressed state of anxiety. Most of the adverse effects of β-blockers are associated with the blockade of β 2 receptors. The need to control the prescription of β-blockers and the side effects that occur (bradycardia, hypotension, bronchospasm, increased signs of heart failure, heart block, sick sinus syndrome, fatigue, insomnia) lead to the fact that the doctor does not always use these drugs. Main medical errors when prescribing β-blockers are the use of small doses of drugs, their appointment less often than necessary, and the abolition of drugs when heart rate at rest is less than 60 beats / min. It should also be borne in mind the possibility of developing a withdrawal syndrome, and therefore β-blockers must be canceled gradually.

Calcium channel blockers (calcium antagonists). The main point of application of drugs of this group at the cell level are slow calcium channels, through which calcium ions pass into the smooth muscle cells of blood vessels and the heart. In the presence of calcium ions, actin and myosin interact, providing contractility of the myocardium and smooth muscle cells. In addition, calcium channels are involved in the generation of pacemaker activity of the cells of the sinus node and the conduction of an impulse along the atrioventricular node.

It has been established that the vasodilating effect caused by calcium antagonists is carried out not only through a direct effect on the smooth muscles of the vascular wall, but also indirectly, through the potentiation of the release of nitric oxide from the vascular endothelium. This phenomenon has been described for most dihydropyridines and isradipine, and to a lesser extent for nifedipine and non-hydropyridine drugs. For long-term treatment angina from dihydropyridine derivatives, it is recommended to use only prolonged dosage forms or long-acting generation of calcium antagonists. Calcium channel blockers are powerful vasodilators, they reduce myocardial oxygen demand, dilate the coronary arteries. The drugs can be used for vasospastic angina, concomitant obstructive pulmonary diseases. An additional indication for the appointment of calcium antagonists are Raynaud's syndrome, as well as (for phenylalkylamines - verapamil and benzodiazepines - diltiazem) atrial fibrillation, supraventricular tachycardia, hypertrophic cardiomyopathy. Of the calcium antagonists in the treatment of coronary artery disease, the following are used: nifedipine of immediate action 30-60 mg / day (10-20 mg 3 times) or prolonged action (30-180 mg once); verapamil immediate action (80-160 mg 3 times a day); or prolonged action (120-480 mg once); diltiazem immediate action (30-60 mg 4 times a day) or prolonged action (120-300 mg / day once); long-acting drugs amlodipine (5-10 mg / day once), lacidipine (2-4 mg / day).

Activation of the sympathoadrenal system by dihydropyridines (nifedipine, amlodipine) is currently regarded as an undesirable phenomenon and is considered the main reason for a slight increase in mortality in patients with coronary artery disease when taking short-acting dihydropyridines with unstable angina, acute infarction myocardium and, apparently, with their long-term use by patients with stable angina pectoris. In this regard, it is currently recommended to use retard and prolonged forms of dihydropyridines. They do not have fundamental differences in the nature of the pharmacodynamic action with short-acting drugs. Due to the gradual absorption, they are deprived of a number of side effects associated with sympathetic activation, which are so characteristic of short-acting dihydropyridines.

AT last years data have appeared indicating the possibility of slowing down the damage to the vascular wall with the help of calcium antagonists, especially in the early stages of atherosclerosis.

Amlodipine (norvasc, amlovas, normodipine) is a third-generation calcium antagonist from the group of dihydropyridines. Amlodipine dilates peripheral vessels, reduces afterload of the heart. Due to the fact that the drug does not cause reflex tachycardia (since there is no activation of the sympathoadrenal system), energy consumption and myocardial oxygen demand are reduced. The drug expands the coronary arteries and enhances the supply of oxygen to the myocardium. Antianginal effect (reducing the frequency and duration of angina attacks, daily requirement in nitroglycerin), increased exercise tolerance, improved systolic and diastolic function of the heart in the absence of a depressant effect on the sinus and atrioventricular node and other elements of the cardiac conduction system put the drug in one of the first places in the treatment of angina pectoris.

Lacidipine is a third-generation calcium antagonist drug with high lipophilicity, interaction with the cell membrane, and independence of tissue effects from its concentration. These factors are leading in the mechanism of anti-atherosclerotic action. Lacidipine has a positive effect on the endothelium, inhibits the formation of adhesion molecules, the proliferation of smooth muscle cells and platelet aggregation. In addition, the drug is able to inhibit peroxidation of low-density lipoproteins, i.e., it can affect one of early stages plaque formation.

In the European study of the effect of lacidipine on atherosclerosis (European Lacidipine Study on Atherosclerosis, ELSA), the carotid intima-media thickness was compared in 2334 patients with arterial hypertension during 4 years of therapy with lacidipine or atenolol. In the patients included in the study, the carotid arteries were initially normal and/or altered. Treatment with lacidipine was accompanied by a significantly more pronounced decrease in the thickness of the "intima-media" in comparison with atenolol, both at the level of the bifurcation and the common carotid artery. During treatment with lacidipine compared with atenolol, the increase in the number of atherosclerotic plaques in patients was 18% less, and the number of patients in whom the number of plaques decreased was 31% more.

Thus, calcium antagonists, along with pronounced antianginal (anti-ischemic) properties, can have an additional anti-atherogenic effect (stabilization of the plasma membrane, which prevents the penetration of free cholesterol into the vessel wall), which allows them to be prescribed more often to patients with stable angina pectoris with damage to arteries of different localization. Currently, calcium antagonists are considered second-line drugs in patients with exertional angina, following β-blockers. As monotherapy, they can achieve the same pronounced antianginal effect as β-blockers. The undoubted advantage of β-blockers over calcium antagonists is their ability to reduce mortality in patients with myocardial infarction. Studies of the use of calcium antagonists after myocardial infarction have shown that the greatest effect is achieved in individuals without severe left ventricular dysfunction, suffering from arterial hypertension, who have had myocardial infarction without a Q wave.

Thus, the undoubted advantage of calcium antagonists is wide range pharmacological effects aimed at eliminating the manifestations of coronary insufficiency: antianginal, hypotensive, antiarrhythmic. Therapy with these drugs also favorably affects the course of atherosclerosis.

organic nitrates. The anti-ischemic effect of nitrates is based on a significant change in hemodynamic parameters: a decrease in pre- and afterload of the left ventricle, a decrease in vascular resistance, including coronary arteries, a decrease in blood pressure, etc. The main indications for taking nitrates are angina pectoris of effort and rest in patients with IHD (also in in order to prevent them), attacks of vasospastic angina pectoris, attacks of angina pectoris, accompanied by manifestations of left ventricular failure.

Sublingual nitroglycerin (0.3-0.6 mg) or nitroglycerin aerosol (nitromint 0.4 mg) are intended for the relief of acute angina attacks due to the rapid onset of action. If nitroglycerin is poorly tolerated, nitrosorbide, molsidomine, or the calcium antagonist nifedipine can be used to relieve an angina attack, chewing or sucking tablets when taken under the tongue.

Organic nitrates (drugs of isosorbide dinitrate or isosorbide-5-mononitrate) are used to prevent angina attacks. These drugs provide long-term hemodynamic unloading of the heart, improve blood supply to ischemic areas and increase physical performance. They are tried to be prescribed before physical exertion that causes angina pectoris. Of the drugs with proven efficacy, the most studied are kardiket (20, 40, 60 and 120 mg/day), nitrosorbide (40-80 mg/day), olicard retard (40 mg/day), monomac (20-80 mg/day ), Mono Mac Depot (50 and 100 mg/day), Efox Long (50 mg/day), Mono Cinque Retard (50 mg/day). Patients with stable angina pectoris I-II FC may intermittent administration of nitrates before situations that can cause an angina attack. Patients with a more severe course of angina pectoris III-IV FC nitrates should be prescribed regularly; in such patients, one should strive to maintain the effect throughout the day. With angina pectoris IV FC (when angina attacks can occur at night), nitrates should be prescribed in such a way as to ensure an effect throughout the day.

Nitrate-like drugs include molsidomine (Corvaton, Sydnopharm, Dilasid), a drug that is different from nitrates in terms of chemical structure, but no different from them in terms of the mechanism of action. The drug reduces vascular wall tension, improves collateral circulation in the myocardium, and has antiaggregatory properties. Comparable doses of isosorbide dinitrate and corvatone are 10 mg and 2 mg, respectively. The effect of Korvaton appears after 15-20 minutes, the duration of action is from 1 to 6 hours (average 4 hours). Corvaton retard 8 mg is taken 1-2 times a day, since the effect of the drug lasts more than 12 hours.

The weak side of nitrates is the development of tolerance to them, especially with prolonged use, and side effects that make it difficult to use them (headache, palpitations, dizziness) caused by reflex sinus tachycardia. Transdermal forms of nitrates in the form of ointments, patches and discs, due to the difficulty of their dosing and the development of tolerance to them, have not been found. wide application. It is also not known whether nitrates improve the prognosis of a patient with stable angina with long-term use, making it questionable whether they are useful in the absence of angina (myocardial ischemia).

When prescribing drugs with a hemodynamic mechanism of action, elderly patients should observe following rules: start treatment at lower doses, monitor closely unwanted effects and always consider changing the drug if it is poorly tolerated and does not work well.

Combination Therapy. Combined therapy with antianginal drugs in patients with stable angina pectoris III-IV FC is carried out according to the following indications: the impossibility of selecting effective monotherapy; the need to enhance the effect of ongoing monotherapy (for example, during a period of increased physical activity of the patient); correction of adverse hemodynamic changes (for example, tachycardia caused by nitrates or calcium antagonists from the group of dihydropyridines); with a combination of angina pectoris with arterial hypertension or cardiac arrhythmias that are not compensated in cases of monotherapy; in case of intolerance to patients of conventional doses of drugs in monotherapy, while small doses of drugs can be combined to achieve the desired effect.

The synergy of the mechanisms of action of different classes of antianginal drugs is the basis for assessing the prospects of their combinations. When treating a patient with stable angina, doctors often use various combinations of antianginal agents (β-blockers, nitrates, calcium antagonists). In the absence of the effect of monotherapy, combination therapy is often prescribed (nitrates and β-blockers; β-blockers and calcium antagonists, etc.).

The results of the ATP-survey study (a review of the treatment of stable angina pectoris) showed that in Russia 76% of patients receive combination therapy with hemodynamically active drugs, while in more than 40% of cases - a combination of nitrates and b-blockers. However, their additive effects have not been confirmed in all studies. In the guidelines European society cardiologists (1997) indicate that if one antianginal drug is ineffective, it is better to first evaluate the effect of another, and only then use the combination. The results of pharmacologically controlled studies do not confirm that combination therapy with a b-blocker and a calcium antagonist is accompanied by a positive additive and synergistic effect in the majority of patients with coronary artery disease. Prescribing 2 or 3 drugs in combination is not always more effective than therapy with one drug in an optimally selected dose. We must not forget that the use of several drugs significantly increases the risk of adverse events associated with effects on hemodynamics.

Modern approach to combination therapy patients with stable angina pectoris implies the advantage of a combination of antianginal drugs of multidirectional action: hemodynamic and cytoprotective.

The main disadvantages of domestic pharmacotherapy of stable angina pectoris include the often erroneous, according to modern concepts, choice of a group of antianginal drugs (nitrates are usually prescribed (in 80%)), the frequent use of clinically insignificant dosages and the unreasonable prescription of combination therapy. large quantity antianginal drugs.

metabolic agents. Trimetazidine (preductal) causes inhibition of fatty acid oxidation (by blocking the enzyme 3-ketoacyl-coenzyme A-thiolase) and stimulates pyruvate oxidation, i.e., it switches myocardial energy metabolism to glucose utilization. The drug protects myocardial cells from the adverse effects of ischemia, while reducing intracellular acidosis, metabolic disorders and damage cell membranes. A single dose of trimetazidine is not able to stop or prevent the onset of an angina attack. Its effects are observed mainly during combination therapy with other antianginal drugs or during course treatment. Preductal is effective and well tolerated, especially in groups high risk the development of coronary complications, such as patients with diabetes mellitus, the elderly and those with left ventricular dysfunction.

The combination of preductal with propranolol was significantly more effective than the combination of this β-blocker with nitrate. Trimetazidine (preductal 60 mg/day), preductal MB (70 mg/day) have an anti-ischemic effect, but more often they are used in combination with the main hemodynamic antianginal drugs.

In Russia, a multicenter, simple, blind, randomized, placebo-controlled, parallel-group study of TACT (Trimetazidin in patients with Angina in Combination Therapy) was conducted, involving 177 patients with angina pectoris II-III FC, partially stopped by nitrates and β-blockers in order to evaluate the effectiveness of preductal in combination therapy with nitrates or β-blockers. Evaluation of the effectiveness of treatment was carried out according to the following criteria: time to 1 mm ST segment depression during exercise tests, time of onset of angina pectoris, increase in exercise duration. It was found that preductal significantly increased these indicators. There are a number of clinical situations in which trimetazidine, apparently, can be the drug of choice in elderly patients, with circulatory failure of ischemic origin, sick sinus syndrome, with intolerance to antianginal drugs of the main classes, as well as with restrictions or contraindications to their appointment. .

Among the drugs with antianginal properties are amiodarone and other "metabolic" drugs (ranolazine, L-arginine), as well as ACE inhibitors, selective heart rate inhibitors (ivabradine, procolaran). They are used mainly as adjuvant therapy, prescribed in addition to the main antianginal drugs.

The problem of drug treatment of patients with coronary artery disease is the lack of adherence of patients to the chosen therapy and their insufficient willingness to consistently change their lifestyle. With drug treatment, proper regular contact between the doctor and the patient is necessary, informing the patient about the nature of the disease and the benefits of prescribed drugs to improve the prognosis. Trying to influence the prognosis of the life of patients with the help of drug therapy, the doctor must be sure that the drugs prescribed by him are actually taken by the patient, and at the appropriate doses and according to the recommended treatment regimen.

Surgery. With the ineffectiveness of drug therapy, surgical methods of treatment (myocardial revascularization procedures) are used, which include: percutaneous transluminal coronary angioplasty, implantation coronary stents, coronary artery bypass surgery. In patients with coronary artery disease, it is important to determine the individual risk based on clinical and instrumental indicators, which depends on the appropriate clinical stage of the disease and the treatment being carried out. Thus, the maximum efficiency of coronary artery bypass grafting was noted in patients with the highest preoperative risk of developing cardiovascular complications (with severe angina pectoris and ischemia, extensive lesions of the coronary arteries, LV dysfunction). If the risk of CAD complications is low (single artery disease, no or mild ischemia, normal LV function), surgical revascularization is usually not indicated until medical therapy or coronary angioplasty has been proven to be ineffective. When considering the use of coronary angioplasty or coronary artery bypass grafting for the treatment of patients with lesions of multiple coronary arteries, the choice of method depends on anatomical features coronary flow, LV function, the need to achieve complete myocardial revascularization, and patient preference.

Thus, with the current methods of combating cardiovascular diseases (table), it is important for a doctor to be aware of the latest advances in medicine and to make right choice treatment method.

For literature inquiries, please contact the editor.

D. M. Aronov, doctor medical sciences, Professor V. P. Lupanov, Doctor of Medical Sciences State Research Center for Preventive Medicine of the Ministry of Health of the Russian Federation, Institute clinical cardiology them. A. L. Myasnikov Russian Cardiological Research and Production Complex of the Ministry of Health of the Russian Federation, Moscow

A fairly serious disease and its treatment must be approached with all seriousness. Only complex assignment necessary drugs can bring the desired results. It is also worth remembering that only an experienced good cardiologist can prescribe the appropriate therapy. It is not possible to cope with such a task on your own, since it is necessary to take into account not only the individual characteristics of the course of the disease, but also the compatibility of the drugs with each other so that one of them does not neutralize the effect of the other, or, moreover, does not provoke, on the contrary, the deterioration of the patient's condition. To do this, from each group of drugs, the main remedy is selected that will completely neutralize the disease.

It is also very important to pay attention to the causes of the disease - the selection of drugs should be carried out precisely taking into account these features.

Ischemia is a complex disease that requires an integrated approach to treatment. Pills alone will not cope here - it is important to change your lifestyle, reconsider your habits.

Only if the necessary regimen is observed in combination with taking the necessary drugs can the desired result be achieved.

It should also be clearly understood that even if the course of treatment brings excellent results and the disease no longer makes itself felt, it still does not mean that you no longer need to take care of your health. In the case of exposure to the body of provoking factors, the recurrence of the development of pathology is again very large. If all the recommendations of the attending physician are followed, the probability is high that the disease will indeed no longer return. But at the same time, it is very important to pay attention to taking medications that help maintain normal heart function.

Selection of therapy

First of all, one must take into account the fact that therapy should be selected based on the following factors:

• causes of coronary artery disease;
• goal of therapy. The therapy can be supportive (after the main course of treatment and stabilization of the condition), to relieve acute attack, recovery after surgery, etc.;
• accompanying illnesses;
• how advanced the disease is, the features of its course, at what stage.

Of course, it is necessary to take into account the individual characteristics of the patient's body. He may be allergic to some prescribed drugs, have an individual intolerance. All this is very important for the doctor to know before compiling a list of recommendations for taking the necessary medications.

Additional measures

In addition to taking medication, it is very important to eliminate the impact of absolutely all provoking factors:

• lowering blood pressure. and IHD - often not only complement each other, but also separately provoke complications. To prevent this, it is very important to monitor your blood pressure, avoiding not only its smooth and stable increases, but also sharp jumps. It is also important to control your diet. It is obesity that in many ways provokes an increase in blood pressure, so you should give up fatty foods (especially animal fats), as well as quickly digestible carbohydrates;
• control of blood cholesterol levels. To do this, it is necessary to minimize the consumption of sour cream, butter and chicken eggs;
• reduction in fluid intake. Too much fluid intake contributes to the formation of various edema, which should be avoided in this case. With the accumulation of a large amount of fluid in the body, the volume of blood increases, which significantly increases the load on the heart;
• quitting smoking and alcohol abuse;
• normalization of sugar. To do this, you need to reduce the consumption of sweets in food;
• elimination of other provoking factors, namely the control of one's lifestyle. For example, it is necessary to have physical activity in the life of such people, but at the same time, physical activity should be moderate, not cause pain and other unpleasant sensations. Ideal for this is swimming or hiking in the fresh air. This will simultaneously help to solve several problems: promotes blood thinning, prevents the occurrence of edema, as well as obesity.

If the data simple recommendations are not observed, then even with the completion of a high-quality and effective course of treatment, coronary artery disease will soon return again, since the provoking factors will in fact not go anywhere and will contribute to the resumption of the acute phase of the disease.

Groups of required drugs

As mentioned earlier, it is necessary A complex approach to the treatment of IBS. When choosing medications, you should follow exactly the same tactics to achieve a long-term desired result. Next, consider the main groups of drugs that are used in the treatment of this disease.

Pressure reducing

High blood pressure has a negative effect on the functioning of the heart muscle. This is due to the fact that the clamped vessels pass oxygen worse, which causes oxygen starvation of the heart. Therefore, to control your pressure and keep it normal is the most important task in IHD.

To do this, you need to use the following drugs:

• ACE inhibitors. They block the action of substances that increase blood pressure, and also minimize the negative impact of other components on the heart, kidneys, and liver. That is, this medicine contributes precisely to the systematic reduction of pressure;
• diuretics. Diuretics not only help lower blood pressure and minimize the development of hypertension, but also prevent the development of congestion in heart failure. It is also very important if there is a risk of developing cerebral edema, pulmonary edema. Sometimes in the early stages of hypertension, diuretics are completely able to stabilize blood pressure on their own without the use of any other drugs. The most important thing is to also minimize salt intake, as it contributes to fluid retention in the body and thereby blocks the action of diuretics.

In coronary heart disease, such medications will be required in order to prevent significant increases in blood pressure, as this dramatically and significantly increases the load on the heart muscle, so such drops should be avoided.

Improving the work of the heart

In this case, the treatment of coronary heart disease includes a variety of drugs that are aimed at solving a variety of problems. Sometimes, at first glance, it may seem that some drugs have absolutely nothing to do with this problem, but it is always worth remembering first of all that all organs in the body are interconnected and therefore problems with some entail problems with other bodies. That is why it is so important for serious heart problems to control the health of other organs.

So, the main groups of drugs that contribute to the normalization of the heart can be divided into the following main large groups:

• beta blockers. Such drugs block the effect of adrenaline on the heart muscle, or rather, inhibit its production in the body. With serious problems with the heart, any experience is destructive and therefore this factor is very important in this case. Also, these drugs can eliminate arrhythmia, help lower blood pressure and reduce heart rate. The drugs are contraindicated in asthma and diabetes. Widely used after myocardial infarction. (Anaprilin, Metoprolol);
• drugs that reduce blood viscosity. The thicker the blood in a person, the harder it is for the heart to pump it, and also the higher the risk of blood clots. The most commonly used for this purpose is Aspirin. It is indicated for use mainly after surgery, as well as for the prevention of blood clots, if there is a predisposition or heredity to this. In more difficult situations, it is necessary to use drugs to dissolve blood clots (if a blood clot has already formed, but there is no way to remove it);
• drugs to lower sugar levels. But at the same time, it must immediately be said that there is little hope for such drugs if the patient does not follow the basic recommendations, namely the diet;
• lowering cholesterol. It is this indicator in the blood that contributes to the development, as well as hypertension. Ideally, if it is as small as possible in the blood of patients with coronary artery disease. For this, it is also necessary, first of all, to follow a diet and minimize the consumption of animal fats. But it will not be possible to reduce such an indicator in one day, and therefore, if necessary, it is very important to start taking drugs in a timely manner to stabilize this indicator in the body. For this purpose, statins are prescribed. Most often, the doctor prescribes a permanent intake of this group of drugs, but here it is important to approach this issue with all seriousness, since the approach should only be comprehensive and nothing else. Taking drugs will not be effective without dieting, and a diet without drugs will also not bring the expected results. That is why it is so important to strictly adhere to all the doctor's recommendations, not only in matters of taking drugs directly, but also in relation to nutrition;
• contraindications and side effects. The action of drugs is aimed at reducing the frequency of the heart muscle, but at the same time increasing its intensity. Digoxin;
• nitrates. The drugs of this group are used directly for the relief of an attack. They help expand coronary vessels and veins to reduce blood flow to the heart, which helps to reduce the load on it.
  Nitroglycerine

  The most commonly used of this group is nitroglycerin. It reduces the oxygen starvation of the heart (since it reduces its need for oxygen), and also minimizes pain or eliminate them altogether. The main disadvantage of nitrates is that the body becomes addictive to them and therefore, with prolonged use, they cease to perform their functions and stop angina attacks. That is why they are prescribed for a long time only in severe forms. At the same time, even if short term stop taking them, then soon they will again have the desired effect on the patient's body.
  Any medication for coronary heart disease can only be prescribed by a doctor, since many of these drugs can have a lot of side effects and contraindications, and even with similar symptoms An excellent remedy for one patient may be fatal for another. The doctor should always take into account the individual characteristics of each patient and, in accordance with them, draw up a list of recommendations. Also, before that, you need to go through comprehensive examination to identify comorbidities and degree of coronary artery disease.

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However, with timely and active start therapeutic measures can slow down the development of the disease, significantly increase the duration and quality of life of the patient.

Risk factors

The key to successful IHD treatment is the elimination of all risk factors:

• lifestyle change,
• lowering blood pressure,
• healthy eating and sleep
• normalization of blood sugar, cholesterol,
• smoking cessation,
• physical activity, etc.

Medical treatment of coronary artery disease

More than half of the success can be achieved without resorting to drugs. But for the greatest effect it is necessary to take medications that maintain normal pressure, cholesterol and blood viscosity. It is necessary to take medicines constantly, throughout life. The success of the treatment depends on this.

With a sharp deterioration in well-being ( decompensation) hospital treatment and admission may be necessary additional medicines. This is especially true for patients in an advanced stage of the disease and those suffering from heart failure. With the right treatment, these cases can be minimized. How less patient calls an ambulance, and the less often there is a need for treatment in the hospital, the better the quality of control over the disease.

Surgical intervention for IHD

Surgical methods are used in case of severe atherosclerosis of the coronary arteries, since no drug can reduce the size of the cholesterol plaque or expand the lumen of the artery, except for surgical intervention. AT heavy In cases of congestive heart failure, a heart transplant remains the only effective treatment.

Indications for hospitalization

• New onset chest pain (angina pectoris)
• New onset or severe arrhythmia
• Progressive angina
• Decompensation of heart failure (a sharp deterioration in well-being, accompanied by an increase in edema, shortness of breath, changes in the ECG)
• Suspicion of myocardial infarction and other acute conditions
• Preparation for surgical treatment

In other cases, IHD is successfully treated at home.

What drugs are used to treat coronary artery disease

Drugs that lower blood pressure

High blood pressure negatively affects the vessels of the heart and other organs, causing them to shrink even more and receive less oxygen. Reduction and constant maintenance of normal blood pressure is a key factor in the treatment of coronary artery disease. The target level of blood pressure in IHD is 140/90 mm Hg. and less for most patients, or 130/90 for patients with diabetes or kidney disease. For severely ill patients, even lower numbers are recommended. In the vast majority of cases, to achieve this level of blood pressure, a constant intake of antihypertensive drugs is required.

ACE inhibitors

This is a class of drugs that block the angiotensin-2 enzyme, which causes high blood pressure and other negative effects on the heart, kidneys, and blood vessels. AT recent times proven set positive effects ACE inhibitors on the prognosis in patients with coronary artery disease, so they are prescribed as widely as possible, in the absence of contraindications. These include, for example, enalapril, lisinopril, perindopril and others. With prolonged use, they can cause a cough, not suitable for all patients. Used as prescribed by a doctor.

Angiotensin receptor blockers

These drugs allow you to block not angiotensin-2 itself, but its receptors located in various organs, including the heart. In some cases, this is much more efficient. ARBs are less effective at lowering blood pressure than ACE inhibitors, but they do have several additional beneficial effects on the heart and blood vessels. In particular, some of them are able to stop the growth of the heart muscle (hypertrophy) and even reduce it by a few percent. They are used in all groups of patients, and especially in those who do not tolerate ACE inhibitors.

The use is long-term, life-long, as directed by a doctor. Examples of drugs: losartan (Cozaar, Lozap, Lorista), valsartan (Valz, Diovan, Valsakor), candesartan (Atakand), telmisartan (Micardis) and others.

The choice of a specific drug, the scheme of its use and dose is within the competence of the doctor, since it is necessary to take into account the individual characteristics of the course of the disease and concomitant diseases.

Drugs that improve heart function

Beta blockers

They block the receptors for adrenaline and other stress hormones in the heart. Reduce heart rate and blood pressure. They have a beneficial effect on the heart during arrhythmia and can eliminate it.

Recommended for permanent use in all patients after myocardial infarction and preinfarction state, as well as with left ventricular dysfunction, regardless of the presence of heart failure, in the absence of contraindications. The use can be long-term or short-term, only as prescribed by a doctor. Most of them are contraindicated in bronchial asthma, many increase blood sugar and are not used in diabetes.

Examples of drugs: anaprilin, metoprolol (Egilok), bisoprolol (Concor), etc.

Nitrates

The main drugs for stopping (eliminating) an attack. These include drugs such as nitroglycerin ("Nitromint"), isosorbide dinitrate ("Isoket") and mononitrate ("Monocinque"), etc. They act directly on the coronary vessels and lead to their rapid expansion, and also reduce blood flow to heart due to the expansion of deep veins, which can store blood. All this facilitates the work of the heart and reduces its need for oxygen, which means it reduces oxygen starvation and pain.

Currently, nitrates are used mainly for the relief of angina attacks, and for permanent use in severe patients with chronic heart failure. All nitrates are addictive, and their effect decreases over time, but after a short-term withdrawal, it is restored again.

cardiac glycosides

Digoxin, corglicon, etc. Strengthen the contractions of the heart muscle and slow down their frequency. Currently, they are used in the treatment of coronary artery disease infrequently, mainly with atrial fibrillation and pronounced edema. They have many side effects, especially in combination with diuretics, and therefore should be prescribed by a doctor only after a thorough examination.

Cholesterol-lowering drugs

• the level of total cholesterol should be no more than 5 mmol / l,
• the level of low-density lipoprotein (“bad”) cholesterol is not more than 3 mmol / l,
• high-density lipoprotein (“good”) cholesterol level of at least 1.0 mmol / l.

The atherogenic index and the level of triglycerides also play a role. In severely ill patients (for example, with concomitant diabetes mellitus), these indicators are recommended to be monitored even more strictly.

Target cholesterol levels are achieved with a special diet and medications. In most cases, diet alone is not enough, but without it, medication will not be as effective. Modern drugs can significantly lower cholesterol levels, but they must be taken constantly. Basically, drugs of the statin group (atorvastatin, simvastatin and others) are used for this. A specific drug is prescribed by a doctor.

Drugs that reduce blood viscosity

The more viscous blood, the more likely the formation of blood clots in the coronary arteries and worse blood supply heart muscle. To reduce blood viscosity, two groups of drugs are used: antiplatelet agents and anticoagulants.

The most common antiplatelet agent is aspirin. It is recommended to take it daily for all patients with coronary artery disease for life at a dose of 70-150 mg per day (in the absence of contraindications, such as stomach ulcers). For patients after heart and vascular surgery, the dose may be increased as prescribed by the doctor, and clopidogrel is added at a dose of 75 mg per day.

In patients with a permanent form of atrial fibrillation, the doctor may prescribe more strong medicine- warfarin anticoagulant, at a dosage that maintains the INR value (blood clotting index) at the level of 2.0 - 3.0. Warfarin dissolves blood clots more actively than aspirin, but can cause bleeding. It is used only as prescribed by a doctor after a thorough examination and under the control of blood tests.

Drugs that control blood sugar (glucose) levels

The modern criterion for the control of diabetes mellitus is the level of glycated hemoglobin (HbA1c). It reflects the concentration of blood sugar over the past week and should not exceed 7%. A single blood sugar test does not reflect the true picture of the course of diabetes.

To achieve the target sugar level, all non-drug measures (diet, exercise, weight loss) should be used, and in case of their insufficiency, specific drug therapy as prescribed by the endocrinologist.

Other drugs

Diuretics (diuretics)

They have two areas of application: in low doses to lower blood pressure (most often in combination with other drugs), in high doses - to remove fluid from the body in congestive heart failure. They tend to increase blood sugar, therefore, in diabetes, they are used in extreme cases.

Antihypoxants

Antihypoxants are drugs that reduce the oxygen starvation of the heart muscle at the molecular level. One such drug is trimetazidine. It is not included in the standard treatment regimens for coronary artery disease, it can be used as an additional tool. Not registered in the USP.

Non-steroidal anti-inflammatory drugs (NSAIDs)

A large-scale study in the USA found harmful action this class of drugs on the prognosis of patients with myocardial infarction. In this regard, drugs such as diclofenac, ibuprofen are not recommended for use in people after a heart attack and equivalent conditions.

Influenza vaccination

Observation

Terms of treatment

Treatment for coronary disease is lifelong and must be carefully planned. During the observation period, it is necessary to strictly adhere to the developed treatment regimen, and in case of side effects or deterioration of the condition, immediately contact your doctor.

Many drugs need to be taken for life. These include aspirin (or similar), blood pressure medications, blood sugar and cholesterol medications, and in some cases other medications. Sudden voluntary withdrawal of the drug or even a dose reduction can lead to sharp deterioration health and decompensation, and this increases the likelihood of deadly complications (heart attack, cardiac arrest, etc.).

Changes in lifestyle and regime must be decisive and unconditional. Often, small flaws in the diet, such as eating too much herring, can lead to a sharp jump in pressure and worsening of the disease.

Visits to the doctor

Usually the doctor himself appoints the date of the next visit. If he didn't, ask him about it. Careful medical supervision and regular check-ups are a necessary and important component of treatment. If you are not sure or doubt the adequacy of your doctor's prescriptions, or you want to get additional advice, contact a specialized consultative or diagnostic cardiology center.

Preventive hospitalizations

In the former USSR, such a phenomenon as hospitalization for prophylaxis was widespread. In the case of coronary artery disease, such a strategy of therapy is not optimal either in terms of the quality of disease control or in terms of patient adherence to treatment, and it should be avoided.

Treatment with interruptions, from time to time, does not provide the necessary control over risk factors and the course of the disease in IHD. Patients begin to lean towards the idea that they will be "treated", after which they will again take up their old life, and everything will be as before. This is a big misconception, which leads to a refusal to constantly take medications, large fluctuations in blood and pressure indicators, and a lack of control over the disease.

For one or two weeks spent in the hospital once every half a year, it is impossible to achieve a real change in the course of the disease, except for some symptomatic improvement. Many patients perceive this improvement as a small victory over the disease, and continue to live their old lives. However, this is not at all true: coronary disease continues to progress without lifestyle changes and maintenance medication, ending in sudden death or a heart attack. You can reduce your risk and prolong life only with a long-term, and not periodic, therapeutic effect.

Ischemic heart disease - coronary artery disease - is one of the most common and insidious. According to the World Health Organization (WHO), this disease claims about 2.5 million lives annually. Publication of the diary of a doctor who underwent heart surgery. provoked a lively response. What was the primary reason for urgent surgical intervention? How to avoid such a fate? What specifically needs to be done for this, what conditions to comply with? Today we will try to answer these questions.

Medical textbooks say that coronary heart disease is chronic illness caused by insufficient blood supply to the heart muscle. The word "ischemia" in translation from Greek means "to retain blood."

In the vast majority of cases (up to 98 percent), cardiac ischemia develops as a result of atherosclerosis of the arteries of the heart, that is, their narrowing due to the so-called atherosclerotic plaques that form on the inner walls of the arteries.

The normal functioning of the heart is ensured by the flow of blood through the vessels called coronary vessels, since they, like a crown, crown the heart from above.

Coronary arteries form the corridors through which blood passes, providing the heart with oxygen and nutrition. In those cases when these corridors are clogged with all sorts of junk - blood clots, plaques - myocardial cells, deprived of the influx of fresh blood, begin to experience a sharp oxygen starvation, and if the blood flow is not restored, they will inevitably die - necrosis of a section of the heart muscle, then what called myocardial infarction.

Most often, coronary heart disease affects strong, able-bodied men aged 40 to 60 years. Women suffer from this heart disease much less often. The reasons, according to scientists, lie in the healthier lifestyle that women lead, beneficial effect female sex hormones.

Doctors also drew attention to the fact that ischemic disease - frequent companion purposeful people or, conversely, reflective melancholics with reduced vitality, constant dissatisfaction with their position and prone to blues.

Numerous studies have identified many other risk factors that contribute to the onset and progression of coronary heart disease. Here are just a few of them: hereditary predisposition, sedentary image life, overeating, overweight, smoking and alcohol, high content lipids, blood cholesterol, high blood pressure, disorders carbohydrate metabolism, in particular diabetes mellitus.

Cardiologists distinguish several forms and variants of the course of coronary heart disease. The most severe form is myocardial infarction, often leading to a tragic outcome. But besides a heart attack, there are other manifestations of coronary artery disease, which can sometimes last for years: atherosclerotic cardiosclerosis, chronic heart aneurysm, angina pectoris. At the same time, exacerbations alternate with periods of relative well-being, when patients seem to forget about their illness for a while.

Ischemic heart disease may first manifest as a heart attack. So, every second myocardial infarction affects people who have never been diagnosed with angina pectoris or cardiosclerosis.

Usually, initial symptoms CHD become seizures acute pain behind the sternum - what doctors in the old days called "angina pectoris", and modern doctors call angina pectoris. Angina pectoris is dangerous and insidious enemy, and the likelihood of developing a severe heart attack increases sharply with the frequency and exacerbation of angina attacks, their occurrence at rest or at night.

With angina pectoris, patients often complain that the chest seems to be surrounded by an iron hoop that prevents breathing, or they say that they feel heaviness, as if an exorbitant load has squeezed the chest.

Before, therapists talked about two types of angina pectoris, which, depending on their clinical picture, were called in one case - angina of exertion, in the other - of rest. The first, according to doctors, is provoked by physical activity or emotional experiences, causing spasm vessels of the heart. rest angina pectoris, in which pain attack developed for no apparent reason, and sometimes even during sleep, was considered a much more serious disease, threatening severe complications, up to a heart attack.

Over time, the terminology, classification, and most importantly, the tactics of treating angina pectoris have changed significantly. Angina pectoris, the attack of which can not only be predicted in advance, but also prevented by taking medications, has become known as stable. Angina at rest, occurring suddenly, in a state of relaxation, sleep, or with little physical exertion, is called unstable.

At the onset of the disease, a “standard” pain attack usually occurs during physical work and, as a rule, disappears two to three minutes after its termination. The duration of a severe attack can last 20-30 minutes, if it cannot be removed, then there is a real danger of developing irreversible necrotic changes in myocardial tissue.

Most often, pain during an attack is localized behind the sternum, at the level of the upper third of the sternum and somewhat to the left. Patients define pain as pressing, breaking, bursting or burning. At the same time, its intensity varies: from intolerable to barely pronounced, comparable to a feeling of discomfort. Often the pain radiates (radiates) to the left shoulder, arm, neck, lower jaw, interscapular space, shoulder blade. The attack begins unexpectedly for the patient, and he involuntarily freezes in place. In a severe attack, pallor of the face, sweating, tachycardia, an increase or decrease in blood pressure can be observed.

The most important sign of stable angina pectoris is the appearance of retrosternal discomfort at the time of physical exertion and the cessation of pain 1-2 minutes after the load is reduced. Often an attack of angina pectoris is provoked by frost or cold wind. Facial cooling stimulates vascular reflexes to maintain body temperature. As a result, vasoconstriction and an increase in blood pressure occur, while oxygen consumption by the myocardium increases, which provokes an attack.

With unstable angina, a person sometimes wakes up unexpectedly in the middle of the night from pressing pains in the region of the heart. Except typical forms angina pectoris there are so-called arrhythmic and asthmatic equivalents of angina, more often observed in patients after myocardial infarction. With the arrhythmic equivalent of angina pectoris, a heart rhythm disturbance occurs; with an asthmatic variant, an attack of shortness of breath or suffocation appears. It should be noted that in this case, pain directly in the area of ​​\u200b\u200bthe heart may be absent.

More recently, the diagnosis of coronary heart disease was made on the basis of patient complaints, ECG data taken during an attack or during a special study, when the patient is given dosed physical activity. Patients call this study a “bicycle”, and doctors call it a “bicycle ergometric test with a dosed stepwise increasing load”. Today, there is an even more advanced method for diagnosing coronary artery disease, recognized throughout the world as the "gold standard" - coronary angiography.

Coronary angiography appeared at the junction of several medical disciplines at once - surgery, radiology and computer technology. Thanks to this method of research, it is possible to accurately determine the localization and degree of damage to the coronary arteries of the heart, and sometimes immediately conduct effective treatment.

Through a small incision, a thin catheter is inserted into the artery of the thigh or shoulder and advanced to the heart. Then a contrast agent is introduced into the catheter, which allows you to clearly see all the coronary vessels on the monitor, assess the degree of their narrowing (stenosis), the number of aneurysms, blood clots and atherosclerotic plaques. If the doctor sees such a plaque on the wall of the coronary vessel that disrupts normal blood flow, he can turn the diagnostic procedure into a therapeutic one. To do this, observing the image on the screen, the doctor brings a special spring through the catheter to the damaged part of the vessel - a stent, which, straightening out, presses atherosclerotic plaques into the walls of the artery. The stent prevents narrowing of the walls of the artery, improves blood flow to the myocardium, eliminating the symptoms of coronary heart disease.

The entire stenting procedure takes about forty minutes and does not cause discomfort. The result, however, patients begin to experience almost immediately - pain in the region of the heart disappears, shortness of breath decreases, and working capacity is restored. Due to its relative simplicity and availability, stenting has become one of the most common surgical methods for the treatment of coronary heart disease.

Reduce the heart's need for oxygen different ways. For example, the expansion of peripheral vessels - arteries and veins. Or by decreasing the strength and frequency of heart contractions. For the treatment of stable angina, physicians use drugs belonging to various chemical and pharmacological groups. The most widely used drugs are three groups: nitro compounds, beta-blockers and the so-called calcium ion antagonists.

Of nitrates, nitroglycerin and its long-term (prolonged) action derivatives, such as sustak, nitrong, sustanit, nitromac, are used to prevent angina attacks, providing a constant concentration of nitroglycerin in the blood.

In the human body, nitroglycerin is easily absorbed by the mucous membranes. In the stomach, it does not decompose, but is less effective than when absorbed through the mucous membrane of the mouth. Therefore, nitroglycerin tablets must be placed under the tongue until completely resorbed. Nitroglycerin quickly causes the expansion of the coronary vessels, and the pain disappears. Without eliminating the causes of angina pectoris, nitroglycerin nevertheless often allows the patient to safely endure up to 20-30 attacks. This time is enough for the development of collaterals - bypass coronary vessels that deliver blood to the myocardium.

The most common tablet form of nitroglycerin. The maximum effect is reached within a minute or two after taking the pill under the tongue. Like other drugs, nitroglycerin has its own side effects. For example, a headache, which can be quite intense. Fortunately, no serious consequences unpleasant feeling does not, and soon the headache goes away on its own.

Headache during the first doses of nitroglycerin is caused by vasodilation and indicates that the drug is working. After several doses, this phenomenon disappears, but the effect on the vessels of the heart remains, so the dose should not be increased.

Nitroglycerin is rapidly destroyed by heat. Store it in the refrigerator and check the expiration date.

If you have angina pectoris, carry the drug with you at all times and take it immediately if you experience pain. In this case, it is advisable to sit or lie down to avoid a sharp drop in blood pressure.

If the pain does not go away, then after 1-3 minutes you can put a second tablet under the tongue and, if necessary, a third. The total daily dose of nitroglycerin is not limited.

To prolong the action of the drug, nitroglycerin is placed in capsules of different sizes, which are successively dissolved, releasing the active ingredient and providing an effect for 8-12 hours. Various patches have also been created with a duration of action of 24 hours, which are glued to the skin.

Sustak, a preparation of depot nitroglycerin, is widely used, which is produced in two dosages: 2.6 mg each (sustak-mite) and 6.4 mg each (sustak-forte). This drug is taken orally (but not under the tongue!). The tablet does not need to be broken, chewed, but should be swallowed whole. The effect of the drug begins within 10 minutes after ingestion. Due to the gradual resorption of the tablet, a long-term preservation of the effective concentration of nitroglycerin in the blood is ensured.

You need to know: Sustak is contraindicated in glaucoma, increased intracranial pressure, and stroke!

Beta-blockers are very effective in the treatment of coronary disease and angina pectoris, which reduce myocardial oxygen demand and increase the heart's resistance to physical activity. Very important for treatment and such properties of beta-blockers as their antiarrhythmic effect, the ability to lower high blood pressure, slow down heart rate, which leads to a decrease in oxygen consumption by the myocardium.

The most widely used propranolol (anaprilin, inderal, obzidan). It is desirable to start with a small dose of the drug: 10 mg. 4 times a day. This is especially important for the elderly and patients with complaints of shortness of breath. Then the dose is increased by 40 mg. per day every 3-4 days until reaching 160 mg / day (divided into 4 doses).

Propranolol is contraindicated in severe sinus bradycardia (rare heartbeat), atrioventricular blockade of any degree, in bronchial asthma, exacerbation of gastric ulcer and duodenal ulcer.

Somewhat inferior to propranolol in the effectiveness of oxprenolol (trazikor). However, it is more slowly excreted from the body, so you can take it three or even twice a day (20-80 mg per dose). Oxprenolol is also contraindicated in bronchial asthma, obliterating and angioedema of the vessels of the extremities (endarteritis, Raynaud's disease).

Atenolol has the longest duration of action (0.05-0.1 g of the drug is enough to take once a day), metoprolol has a somewhat less long-term effect (0.025-0.1 g twice a day); talinolol should be taken at 0.05-0.1 g at least three times a day.

If these drugs cause a significant slowdown in heart rate, it is advisable to try pindolol (visken), which in some cases even increases the rate of heart contractions. However, it should be remembered that this drug is able to enhance the action of antidiabetic agents and insulin and is not combined with antidepressants.

Treatment with beta-blockers, especially at first, should be carried out by regularly checking blood pressure, pulse and under ECG monitoring. It is extremely important to know that the sudden withdrawal of beta-blockers can cause a sharp exacerbation of angina pectoris and even the development of myocardial infarction, therefore, if necessary, their withdrawal should be reduced gradually, while supplementing drug therapy with drugs from other groups.

According to the mechanism of action and clinical efficacy, amodarone (cordarone) is close to beta-blockers, which has vasodilating effect, leading to an increase in the volume of blood flowing to the myocardium. It also reduces myocardial oxygen consumption by reducing the number of heartbeats and reducing peripheral vascular resistance in the muscles and tissues of the body. Kordaron is used in severe forms of arrhythmias (atrial and ventricular extrasystoles, ventricular tachycardia, arrhythmias against the background of heart failure). However, cordarone is contraindicated in diseases of the thyroid gland, it cannot be combined with the intake of beta-blockers, diuretics, corticosteroids. In addition, this drug may enhance the effect of taking anticoagulants.

Another group of drugs that can stop the onset of coronary disease are calcium ion antagonists. These drugs provide a more complete relaxation of the heart muscle during rest - diastole, which contributes to a more complete blood supply and restoration of the myocardium. In addition, calcium antagonists dilate peripheral blood vessels - therefore they are especially recommended for the treatment of coronary heart disease when it is combined with hypertension and some forms of heart failure.

For the prevention and treatment of angina pectoris and other complications of coronary heart disease, several drugs from the group of anticalcium agents are used. In order to prevent angina attacks and treat arrhythmias, verapamil (its other names are isoptin and phenoptin) and procorium (gollopamil) are used. These drugs should be handled with caution in patients with liver disease. These drugs are contraindicated in slow heart rate, chronic heart failure.

Many anticalcium drugs have a number of side effects, causing headache, nausea, constipation, drowsiness, fatigue. However, most cardiologists believe that one should not give up anticalcium drugs, but use them strictly according to indications, under the supervision of a doctor.

Nifedipine and drugs synthesized on its basis (adalat, calgard, cordafen, nifecard, nifelate) have a wide spectrum of action. They are used for the prevention and treatment of angina pectoris and arterial hypertension, in the relief of hypertensive crises. It must be remembered that with the abrupt cancellation of these drugs, there may be a "withdrawal syndrome" - a deterioration in the patient's condition. Do not use these drugs together with beta-blockers or diuretics: such "combinations" of drugs can cause a sharp decrease in pressure. They are not recommended to be used in the first week after a heart attack, with increased heart rate, low blood pressure, heart failure, while carrying and feeding a child.

Enduracin is a slow-release nicotinic acid preparation. Walking along gastrointestinal tract, nicotinic acid gradually enters the blood from the enduracin tablet. It is due to this "non-fussiness" of the drug that its effectiveness increases and the risk of possible side effects decreases.

Enduracin is indicated for the treatment of chronic ischemic heart disease, angina pectoris, atherosclerosis of the lower extremities with intermittent claudication. However, it is not indicated for patients with diabetes mellitus, chronic hepatitis, peptic ulcer, gout. Therefore, first consult with your doctor, and when taking the drug once every two months, you need to check your blood sugar.

The drug is available in the form of tablets of 500 mg; the usual dosage is one tablet per day during or after a meal.

How to prevent coronary heart disease

Any disease is easier to prevent than to cure. This wisdom is fully applicable to CHD. Of course, it is difficult to completely eliminate the likelihood of this serious illness, but it is entirely within your power to increase the chances of a long-term healthy and fulfilling life.

For starters, it’s good to determine the degree of deterioration of the heart - make an ECG, determine the level of cholesterol in the blood, consult an experienced cardiologist. Try to assess your lifestyle with a sober look: how you eat, how much time you spend in the air, how much you move.

The need to avoid physical overexertion does not mean giving up physical activity. Morning hygienic gymnastics should become an obligatory element of the regimen. During night sleep functional state the cardiovascular system is reduced, and morning hygienic gymnastics facilitates the inclusion of the body in daily activities. There are many recommendations on the methods of such gymnastics, but, of course, no scheme can replace an individual approach to the choice of physical activity.

The most useful exercises in which rhythmic contractions of significant muscle groups occur. These are brisk walking, slow running, cycling, swimming.

For example, at the age of 50-55, walking should start from a distance of two to three kilometers, gradually increasing the pace and duration of movement. A good load for a trained person is provided by an hourly five-kilometer walk. The most important condition for classes is systematic. A break of one to two weeks leads to the complete disappearance of the healing effect. Therefore, it is important to continue classes in any conditions, in any season, in any weather.

The simplest indicator of your heart's work is your pulse. Its frequency and rhythm make it possible to accurately judge the load experienced by the heart. The pulse rate during physical activity should not exceed 20-30 beats per minute compared to its frequency at rest.

Diet plays an important role in the prevention of coronary disease. You should refrain from fatty meat food. Compensate for this loss with vegetable salads, fruits, apples, unsalted fish. Useful dried apricots, bananas, apricots, peaches, blueberries, cherries, raspberries, cabbage, baked potatoes, rice - foods rich in potassium. Peppers, onions, mustard, horseradish, coriander, dill, cumin are allowed.

DO NOT eat foods high in saturated fats :

Condensed milk, cream, sour cream, butter, cheese, cottage cheese, kefir, yogurt with a fat content above 1%, as well as milk porridges on whole milk.

Pork and cooking fat, margarine, coconut and palm oil.

Pork, lamb, ham, lard, bacon, sausages, frankfurters, sausages, canned meat, fatty meat broths.

Liver, kidneys, lungs, brains.

Red poultry meat, eggs.

Sturgeon, caviar and fish liver.

Bread of the highest quality and crackers from it, confectionery and pasta.

Cocoa, chocolate, coffee beans.

Sugar, honey, soft drinks (Fanta, Pepsi, etc.)

Beer, fortified wines, liqueurs.

You CAN consume in moderation (no more than 1-2 times a week) the following foods :

Skinless white poultry, lean beef.

Secondary broth made from lean beef and lean chicken (a portion of meat is boiled in water a second time, the primary broth is drained).

River fish, incl. red.

bran bread and rye flour, crackers from it. Buckwheat.

Potatoes, mushrooms.

Ketchup (unsweetened), mustard, soy sauce, spices, spices.

Tea, instant coffee without sugar.

DO eat the following foods daily :

Vegetable oil for cooking and replacing animal fats.

Vegetables, fruits and berries (fresh, frozen, sugar-free, dried fruits).

Sea fish, incl. fatty (halibut, herring, tuna, sardine). Seaweed.

Oatmeal boiled in water.

Mineral water, fruit juice and fruit drink without sugar.

To prevent an increase in cholesterol levels, it is advisable to use drugs that reduce its content in the blood (crestor, probucol, lipostabil).

Traditional medicine for coronary heart disease

In addition to numerous drugs sold in pharmacies are very expensive, there are many proven folk remedies against angina pectoris and other manifestations of cardiac ischemia.

7 art. tablespoons of a mixture of hawthorn berries and rose hips pour 2 liters. boiling water, leave for a day, strain, squeeze the swollen berries, put the infusion in the refrigerator. Take 1 glass 3 times a day with meals for 2-3 weeks.

Pour 1 tbsp. a spoonful of crushed valerian root 1 cup boiling water, leave overnight in a thermos. Take 1/3 cup 3 times a day 30 minutes before meals. The course of treatment is 2-3 weeks.

Mix 1 tbsp. a spoonful of adonis herb, 2 tbsp. spoons of mint herb, oregano herb, cuff herb, dandelion root, sage herb, deviant peony root, 3 tbsp. spoons of hawthorn leaves, birch leaves, meadow geranium grass, 4 tbsp. spoons of meadowsweet herb. 2 tbsp. collection spoons pour 1/2 l. boiling water and simmer for 5-7 minutes, then insist for several hours. Distribute the solution throughout the day, take before meals.

Pour 3 tbsp. spoons of flowers or leaves of buckwheat sowing 500 ml. boiling water, insist 2 hours, strain. Take 1/2 cup 3 times a day. The course of treatment is 3-4 weeks.

90 g fresh sage, 800 ml. vodka and 400 ml. boiled water insist 40 days in the light in a closed glass container. Take 1 tbsp. spoon before meals.

Insist in 800 ml. vodka and 400 ml. boiled water grass cudweed marsh - 15.0; sweet clover - 20.0; horsetail - 20.0. 1 st. take a spoonful of infusion twice a day.

Insist in 400 ml. vodka and 400 ml of boiled water hawthorn flowers - 15.0; horsetail grass - 15.0; white mistletoe grass - 15.0; leaves of small periwinkle - 15.0; yarrow grass - 30.0. Take a glass of infusion in sips throughout the day.

Infuse peppermint leaves in 500 ml of boiled water - 20.0; wormwood herb - 20.0; common fennel fruits – 20.0; linden heart-shaped flowers - 20.0; alder buckthorn bark - 20.0. Take 1 tbsp. spoon in the morning.

For the treatment of coronary heart disease and angina pectoris, folk medicine uses cereals rich in minerals, vitamins, trace elements, fatty acids. These substances slow down blood clotting, increase the content of useful cholesterol in the blood, and lower blood pressure.

Wheat contains many B vitamins, E and biotin. Ground wheat bran is washed, poured with boiling water and infused for 30 minutes. The resulting slurry can be added to any dish, starting with 1 teaspoon per day, after a week increase the portion to 2 teaspoons. After 10 days, use 1-2 tbsp. spoons 2-3 times a day.

Rice is a good adsorbent, which is widely used in the appointment unloading diets. Rice pre-soaked in cold water is taken 1 tbsp. spoon 3 times a day.

In old clinics, it was recommended for ischemic disease, angina pectoris, hypertensive crises, infusion dried fruits hawthorn (10 g per 100 ml of water, boil for 10-15 minutes). Take 1/2 cup twice a day. Hawthorn tincture is prescribed 20-40 drops three times a day before meals.

One glass of white mistletoe herb infusion for angina pectoris is recommended to drink in sips throughout the day. The duration of treatment is three to four weeks. As a maintenance therapy, an infusion of mistletoe herb is taken 1 tbsp. spoon two or three times a day.

Chamomile petals are brewed at the rate of 1 tbsp. spoon for 0.5 liters of boiling water and drink three times a day for 1/2 cup in the form of heat, adding 1 tbsp. a spoonful of honey in two glasses.

You can not do in the treatment of angina pectoris without all your favorite garlic, onions and honey. Here are some recipes.

300 g of washed and peeled garlic put in a half-liter bottle, pour alcohol. Insist for three weeks, take 20 drops daily, diluted in 1/2 cup of milk.

Squeeze juice from 1 kg of onion, add 5 tbsp. spoons of honey, mix. Take the prepared mixture of 1 tbsp. spoon 3 times a day 1 hour before meals. The course of treatment is 3 weeks.

Motherwort tincture is widely used in the prevention of angina pectoris and other cardiovascular diseases, which is prescribed 30-40 drops in a glass of water three times a day.

Herbalists recommend making warm foot or general therapeutic baths from the infusion of the following plants: swamp cudweed, oregano, birch leaves, linden flowers, sage, thyme and hop cones - 10 g of each ingredient for two baths. All these plants brew 3 liters of boiling water, soar for 2-3 hours, strain into a bath filled with water. Take a bath (the heart area should not be covered with water) from 5 to 15 minutes after a hygienic shower. After the bath, rub well with 5-6 drops. fir oil area of ​​the coronary vessels (below the nipple).

Nikolay Alexandrov,

Candidate of Medical Sciences

Cardiac ischemia

The most formidable disease among cardiovascular ailments is considered, perhaps, ischemic heart disease. It develops as a result of the formation of atherosclerotic plaques in the arteries of the heart, consisting of fatty substances, cholesterol, calcium. The resulting narrowing of the vessel leads to disruption of the blood supply to the heart, which naturally affects its work.

Ischemic heart disease manifests itself in different ways. It can manifest itself with pain, rhythm disturbances, heart failure, and sometimes it is completely asymptomatic for some time.

And yet most often there are pains. They arise as a result of a mismatch between the heart's need for oxygen (for example, during heavy physical exertion) and the ability of the heart vessels (because they are narrowed due to atherosclerotic plaques) to provide these needs. Thus, pain in the heart, as it were, signals a malfunction in it.

Characteristic for this disease Pain is called angina pectoris, which means "angina pectoris" in Latin. This is probably due to the fact that patients with angina often feel as if some unknown and terrible creature has descended on their chest and is squeezing the heart with its claws, making it difficult to breathe. Pain is most often localized behind the sternum, they are burning, pressing or squeezing, can be carried out in the lower jaw, left arm. But the most important signs of angina pectoris are the following. The duration of pain - no more than 10-15 minutes, the conditions of occurrence - at the time of physical exertion, more often when walking, and also during stress; a very important criterion is the effect of nitroglycerin - after taking it, the pain disappears within 3-5 minutes (they can also disappear when physical activity is stopped).

Why do we describe angina pain in such detail? Yes, because the diagnosis of this disease is often difficult even for a specialist cardiologist. The fact is that, on the one hand, angina pectoris can occur under the guise of other diseases. For example, a burning sensation in the chest is often mistaken for a stomach ulcer or esophageal disease. On the other hand, often similar pains actually have nothing to do with angina pectoris, for example, with osteochondrosis of the spine, cardioneurosis. We will talk about these common diseases separately in the “More about pain in the heart” section.

Of course, you understand that the prognosis for angina pectoris and osteochondrosis is different. A patient with cardioneurosis does not need to see gloomy prospects for his heart at all. At the same time, patients with angina sometimes do not go to the doctor for a long time, believing that they have a sick stomach or spine, and this is dangerous, since angina pectoris is a path to myocardial infarction.

If, with angina pectoris, the vessels of the heart, as a rule, are narrowed but still passable, then myocardial infarction occurs with complete blockage of the arteries and means “necrosis” or, as experts say, necrosis of a section of the heart muscle. A harbinger of a heart attack may be first-time angina pectoris or a change in the nature of pre-existing angina pectoris: increased and increased pain, deterioration in exercise tolerance, the appearance of pain at rest, at night. This type of angina is called unstable. In this case, the patient should immediately consult a doctor!

Myocardial infarction may be the first manifestation of coronary heart disease. It is characterized by severe pressing or squeezing pain in the chest, reminiscent of angina pectoris, but more intense and prolonged; they decrease somewhat, but do not disappear completely after taking nitroglycerin. In such a situation, it is necessary to re-take nitroglycerin, other nitrates (see below) and urgently call an ambulance! Treatment of myocardial infarction is carried out only in hospitals, in the early days - in intensive care units, as there is a threat of serious, life-threatening complications.

In recent years, to dissolve a blood clot that leads to a complete blockage of a heart artery (a blood clot - a blood clot - often forms on an atherosclerotic plaque), special drugs are used that are injected intravenously or directly into the arteries of the heart through catheters. Such treatment is effective only in the first hours of a heart attack. Performed in the early stages of a heart attack and operations aimed at removing a blood clot and restoring the blood supply to the heart - coronary artery bypass grafting, as well as balloon dilatation (expansion) of blood vessels, but more on that later. Let us return to angina pectoris, which, unfortunately, can accompany the patient for quite a long time.

For the treatment of angina pectoris, cardiologists prescribe nitro-containing drugs - nitrates. The most effective are mononitrates (monomak, mononit, monosan, etc.) and dinitrates (negrosorbitol, kardiket, isoket, etc.). Sustak, sustanite, nitrong, trinitrolong, erinite are used somewhat less frequently. Exist various forms release of nitropreparations: in the form of tablets, sprays, ointments, plasters and special plates that are glued to the gums. The mechanism of action of these drugs is that they dilate the vessels of the heart, and also reduce the volume of blood that the heart has to pump, trapping blood in venous system Thus, they facilitate the work of the heart and reduce its need for blood. They should be taken one tablet 2-3 times a day, as well as 30-40 minutes before any physical activity, for example, before going to work. With mild angina, which occurs only with great physical exertion, these drugs are used, as doctors say, “on demand”. Sometimes headaches occur after taking nitrates. In this case, you should change the drug to another from the same group, reduce the dose. In the early days, you can try to take nitrates simultaneously with validol or analgin, or acetylsalicylic acid(aspirin). Headaches that occur at the beginning of treatment usually disappear gradually. Regular intake of nitrates often entails a weakening of the therapeutic effect, therefore, periodic withdrawal of the drug for 2-3 weeks is recommended. For this period, it can be replaced with other drugs, such as Corvaton (Corvasal, molsidomine). If it is not possible to cancel the medicine due to the resumption of pain, then try to take it less often (for example, not 3, but 1-2 times a day, but in a double dose (instead of one - two tablets). Do not forget that nitrates, and in first of all, nitroglycerin, are the most effective means for an attack of angina pectoris.Nitroglycerin acts very quickly and is also quickly excreted from the body, so it can be taken repeatedly.It must be remembered that the activity of nitroglycerin tablets decreases rapidly during storage, so every 3-4 months. vials with tablets should be updated.If you do not have nitroglycerin on hand, then during an attack you can put any other remedy from the nitrate group under the tongue, but in this case the effect comes later, so nitroglycerin is preferable.Nitrates are contraindicated in patients with glaucoma.The second group drugs that are effective for angina pectoris are adrenergic blockers.They reduce heart rate, blood pressure, those m thereby facilitating the work of the heart. This group includes anaprilin, obzidan, metoprolol, atenolol, carvedilol, etc. These drugs should be taken under medical supervision, since, as already mentioned, they slow down the pulse and lower blood pressure. The effect depends on the dose of the drug, so you need to be very careful.

Reception of anaprilin, obzidan usually begins with a dose of 10 mg (0.01 g) 3 times a day, atenolol and metoprolol - 25 mg I -2 times a day. After 1-2 days, the dose of drugs is gradually increased until the onset of the effect, controlling the pulse and pressure. It is necessary to periodically do an electrocardiogram (ECG), as these drugs can cause deterioration in the conduction of heart impulses - heart block.

β-blockers are contraindicated in patients bronchial asthma, patients with diseases of the arteries of the lower extremities, heart blocks, "unregulated" diabetes mellitus. They can cause insomnia and headaches. However, side effects are rare, and in general, drugs are very successfully used for angina pectoris.

As shown recently by multicenter foreign studies, only β-blockers with long-term use prolong the life of patients with coronary heart disease. The third basic medicine (after nitrates and β-blockers) for angina pectoris is aspirin. It prevents the processes of thrombosis and is taken daily at 1/4 tablet (0.125); a special aspirin-cardio is now commercially available. These drugs are contraindicated in peptic ulcer disease. In these cases, they are replaced by curantyl (dipyridamole), ticlid.

In coronary heart disease, especially in the so-called vasospastic angina, a group of drugs is also used - calcium antagonists. These drugs are involved in the exchange of intracellular calcium, causing vasodilation (including the heart), reduce the load on the heart. They also have an antiarrhythmic effect, lower blood pressure. Calcium antagonists include nifedipine, corinfar, diltiazem, verapamil. They are usually prescribed one tablet 3-4 times a day. There are also extended forms that are taken 1-2 times a day and do not cause such side effects as palpitations and redness of the face. These are corinfarretard, nifedilin-retard, adalat, amlodipine, etc.

Recently, drugs that improve metabolism directly in muscle cells have also been used to treat angina pectoris and myocardial infarction. First of all, it is preductal or trimetazidine, mildronate, neoton, etc. With a high level of cholesterol and other "harmful" lipids, special medications are recommended. But this will be discussed below.

You can try to treat angina pectoris medicinal herbs(but of course they should be considered as additional means):

- hawthorn - dried fruits and flowers (10 g per 100 ml of water) boil for 10-15 minutes (flowers 3 minutes), insist and drink half a cup 2-3 times a day.

- chamomile pharmacy - white petals are brewed at the rate of 1 tablespoon per 0.5 l of boiling water and drunk 3 times a day for 1/2 cup in a warm form, adding 1 tablespoon of honey for 3/4 cup

Peppermint - Prepared like chamomile.

Carrot juice, pumpkin seed, decoction of dill seeds are also useful. For the prevention of atherosclerosis, the use of garlic is very good.

This recipe has long been known: take 0.5 liters of honey, squeeze 5 lemons, add 5 heads (not cloves) of garlic ground in a meat grinder, mix everything, leave it in a jar for a week, closed. Drink 4 teaspoons once a day.

Significant progress has been made in the treatment of angina pectoris in recent years. Along with drugs, surgical methods are used - operations on the vessels of the heart, which allow restoring the patency of the arteries and improving the blood supply to the heart. These are, first of all, operations of coronary artery bypass grafting and balloon dilatation of arteries. The essence of coronary artery bypass surgery is that between the artery, in which there are atherosclerotic changes, and the aorta, an additional path is created - a shunt. Such a kind of bridge is formed from the area of ​​the saphenous vein of the patient's thigh, the radial artery, the internal thoracic artery. As a result, blood enters the artery of the heart directly from the aorta, bypassing the atherosclerotic plaque that prevents normal blood flow. There may be several shunts - it all depends on the number of affected arteries. Surgical methods have been widely used since the early 70s. By the way, for the first time in the world, such an operation was performed in our city by surgeon V.I. Kolesov in 1964. Hundreds of thousands of these surgeries are performed annually in the United States today. We are, of course, far behind. However, coronary artery bypass grafting is performed both in our country and in our city in several cardiac surgery centers: City Cardiac Surgery Center (Hospital No. 2), St. Petersburg medical University, Research Institute of Cardiology, Military-medical Academy and regional hospital. The experience accumulated throughout the world of these operations indicates that during the first years after surgical treatment, angina pectoris completely disappears in 85% of patients, and is significantly relieved in another 10%. Subsequently, the beneficial effect may decrease, and the attacks resume. If the three main arteries of the heart involved in its blood supply are affected, then coronary artery bypass surgery significantly reduces the risk of death.

In addition to these operations, less traumatic methods of surgical treatment have been used in recent years, in particular, balloon dilatation of blood vessels (another name is angioplasty of the coronary arteries). During this operation, an atherosclerotic plaque is crushed with a special balloon, which is injected into the artery of the heart under X-ray control without opening the chest and without using a heart-lung machine. Angioplasty is often combined with stenting: after expanding the vessel with a balloon, a stent is installed in place of the former plaque - a special device that expands like a spring inside the vessel and prevents its narrowing. These operations are also quite effective in angina pectoris, for them, as well as for coronary artery bypass surgery, there are certain indications and contraindications.

To resolve the issue of indications for surgery, as well as for diagnostic purposes, patients undergo an X-ray examination of the heart vessels - coronary angiography. This study helps to predict the course of the disease, determines the extent of the operation. As for the surgical methods of treatment for this disease, it should be added that the surgeons did not stop there. New methods are being developed for the destruction of atherosclerotic plaques with a laser, special devices such as microdrills - rotablators, etc. It became possible to look inside the heart vessels (as in fibrogastroscopy - into the stomach) and directly assess the state of the artery, the nature of the plaque with the eye!

But back to earth. So far, our domestic medicine is far from such heights, and nevertheless, the diagnosis of coronary heart disease is carried out at a fairly high level in our country.

Load tests are widely used, simulating physical activity and allowing to evaluate the work of the heart during them. This is a bicycle ergometry, a treadmill is a treadmill.

Recently, 24-hour monitoring has been used to examine patients (recording with a small device that is fixed on the chest, electrocardiograms during the day), echocardiography, as well as completely new methods: magnetic resonance imaging, radionuclide studies of the heart and blood vessels, intracoronary ultrasound scanning.

As you understand, not all of these methods of examination and treatment are still widely available. Therefore, it is high time to think about the prevention of coronary heart disease, and we must start with the so-called risk factors for atherosclerosis, which significantly increase the morbidity and mortality in this disease. These include smoking, high blood pressure, obesity, sedentary lifestyle, unhealthy diet, a special type of behavior, aggravated heredity for coronary heart disease, diabetes mellitus.

In the presence of hypertension, the risk of coronary heart disease increases by 2-3 times, so patients with high blood pressure must be treated. The same applies to patients with diabetes mellitus, in which atherosclerosis develops at an accelerated pace.

The probability of myocardial infarction in smokers is 5 times higher, and its frequency depends on the number of cigarettes used: for those who smoke an average of 1-14 cigarettes per day, the relative risk is 0.9 compared with non-smokers, for those who smoke 15-24 cigarettes, this indicator is 4 3, and smokers 35 cigarettes a day or more - 10. Sudden death from coronary heart disease in smokers is 4.5 times higher than in non-smokers. In our opinion, comments on the issue of the dangers of smoking are unnecessary.

Contributes to the development of coronary heart disease and certain behavior of people. At present, there is reasonable evidence for negative influence seated image life, which allows us to recommend regular physical training for the prevention of heart attack and angina pectoris. Even at the beginning of the 20th century, it was noticed that a typical patient with coronary heart disease is not a weak neurotic, but a strong and energetic, insightful and ambitious person. Subsequently, a special type of behavior was identified, the so-called type A, characteristic of patients with coronary heart disease. Persons with type A behavior are impatient and restless, speak quickly and expressively, they are characterized by liveliness, alertness, tension of the facial muscles, they often clasp their fingers and step over their feet, they have constant feeling lack of time, they are prone to rivalry, hostility, aggressiveness, often forced to suppress anger. It turned out that this behavior is an independent risk factor for coronary heart disease: the incidence in such people is almost 2 times higher than in people with type B behavior, for which these features are not typical. Is it possible, by modifying type A behavior and psychological counseling reduce the risk of coronary heart disease in healthy people? Probably yes. For example, there is evidence that people who have received appropriate psychological help, significantly less frequent recurrent myocardial infarction.

It is known that obesity, malnutrition, and increased blood cholesterol levels lead to the development of coronary heart disease. In obese individuals, myocardial infarction occurs 3 times more often than in lean individuals. With a cholesterol content of 5.2-5.6 mmol / l (normal values ​​- up to 5.2 mmol / l), the risk of death from coronary heart disease doubles. Both obesity and high cholesterol levels are highly dependent on nutrition. It is through the correction of nutrition that one should try to reduce the concentration of cholesterol, body weight, and hence the risk of disease.

By the way, atherosclerosis and coronary heart disease are much less common among the Eskimos of Greenland and in general among the population of the Arctic than among the inhabitants of Western Europe. This is mainly due to the nature of the diet. Residents of the Arctic region consume more protein (the main food is fish, not meat and milk), less carbohydrates and fats.

Perhaps, nutrition should be discussed in more detail. First of all, it is necessary to limit the consumption of animal fats and foods rich in cholesterol, since they are deposited in the vascular wall in the form of atherosclerotic plaques. Fat content in daily diet should not exceed 70-80 g, and it is good if half of this amount falls on vegetable fats and low-energy (so far only imported) margarines. Fats, by the way, are included not only in the composition of butter, lard, sour cream, but also in such products as bread, muffins, sausages, sausages, cheese, cottage cheese, etc. Therefore, despite the restriction of food intake with a lot of fat, the latter are all -they enter the body with other products.

Cholesterol is enemy No. 1. Brains contain it in excess (so forget about jelly!), eggs, sturgeon caviar, kidneys, liver, fatty herring, saury, mackerel, sardines, halibut, flounder, butter, sour cream. Naturally, these products must be excluded. Eating easily digestible carbohydrates also leads to an increase in blood cholesterol levels. Therefore, you can not get carried away with sweets, ice cream, chocolate. Milk lovers will not be pleased. It turns out that milk protein - casein - contributes to an increase in cholesterol. In this regard, cottage cheese, cheeses, whole milk undesirable. Better liquid dairy products.

Protein in the diet should not be limited. But it is better to satisfy the need for them mainly at the expense of not animals (beef, fish, chicken, etc.), but vegetable proteins (soy, peas, peanuts, wheat, etc.).

Food should contain a sufficient amount of vitamins and trace elements that have anti-cholesterol effects. Therefore, the diet must include fresh fruits, vegetables, herbs, berries.

Sea products containing iodine are very useful (seaweed, sea scallop, mussels, squids, shrimps, sea cucumbers). Iodine helps break down cholesterol.

In coronary heart disease, in no case should you overeat. Obesity not only changes the metabolism in the direction of increasing cholesterol levels, but also leads to an increase in the load on the heart. By the way, some patients have angina attacks after a heavy meal. Thus, nutrition can both contribute to the development and be a therapeutic factor in coronary heart disease. Choose what you like! When dietary treatment is ineffective, drugs such as lipostabil, lovastatin, mevacor, zakor (the so-called statin group), as well as clofibrate, cholestyramine, and nicotinic acid are used to lower blood cholesterol. Treatment with these drugs is carried out constantly, under medical supervision, since long-term use of drugs is rare, but can lead to the development of side effects.

Statins are especially popular now in America and Europe. They are prescribed for patients with angina pectoris and those who have had myocardial infarction, even with normal level cholesterol, not to mention the high values ​​of the latter. As shown by the results of multicenter, long-term studies, these drugs significantly reduce the risk of recurrent heart attacks, improve the survival of patients with coronary heart disease. They not only reduce the level of atherogenic LI) guides, preventing the formation of new plaques, but also affect existing plaques. However, these funds have a serious drawback - they are quite expensive. Therefore, if you do not have such opportunities, we recommend starting preventive measures with diet and lifestyle changes. Traditional medicine recommends using the following remedies for atherosclerosis. Sage - 90 g of fresh sage, 800 ml of vodka and 400 ml of water, insist 40 days in the light in a closed glass container. Take 1 tablespoon in half with water in the morning, before meals.

Garlic - 300 g of washed and peeled garlic put in a half-liter bottle and pour alcohol. Insist for 3 weeks and take 20 drops daily in half a glass of milk.

There is another recipe: peel the garlic and pass it through a meat grinder twice, mix 200 g of the resulting mass with 200 g of alcohol. Seal tightly and keep for 2 days. Take 20 drops daily before meals with milk. This course is required to be held every 2 years.

Onion - mix onion juice with honey in a ratio of 1:1, take 2 times a day, 1 tablespoon.

Clover and fireweed - a mixture of clover and fireweed with stems in equal proportions is brewed like tea and drunk throughout the day. By the way, this remedy also improves sleep.

Heather-I Pour a tablespoon of crushed heather into 500 ml of boiling water and boil over low heat for 15 minutes. Insist, wrapping the container, for 2-3 hours, strain. Drink throughout the day, like tea, without dosage.