What kind of disease is ischemia of the heart. Ischemic heart disease: causes, symptoms, diagnosis and treatment

Coronary artery disease (CHD) is a pathological process during which damage is caused to the myocardium due to impaired blood flow in the coronary arteries. That is why medical terminology suggests another name for the disease - coronary heart disease. At the first stage of formation, the disease develops asymptomatically, and only after the patient may experience an attack of angina pectoris. Treatment of pathology can be carried out with the help of medications or surgery. Everything here determines the degree of damage to the pathology.

Risk factors

Like all internal organs, the heart cannot function without a blood supply. For delivery required amount Two coronary arteries supply blood to the myocardium. They arise from the aorta in the form of a crown, and then divide into small vessels. Those, in turn, are responsible for delivering blood to specific areas of the heart muscle.

There is no other way of blood supply to the myocardium, therefore, with thromboembolism of any small vessel, oxygen starvation of the heart occurs, and this already leads to the formation of coronary heart disease.

Coronary artery disease is considered to be the underlying cause of coronary heart disease. It is characterized by overlapping cholesterol plaques or narrowing of the heart arteries. Therefore, the heart does not receive the necessary amount of blood for its normal functioning.

Symptoms

Symptoms of coronary heart disease begin to make themselves felt gradually. The first signs of a lack of oxygen to the myocardium can be recognized while running or walking fast. Violation of myocardial metabolism can be detected by such manifestations as chest pain when a person is at rest. The frequency of angina attacks depends on how much the lumen in the coronary artery has become smaller.

Together with angina pectoris, a person can attend in a chronic form. It is characterized by shortness of breath and increased swelling.

The lumen of the artery is completely closed when the plaque ruptures. These events can cause a heart attack or cardiac arrest. Here, the determining factor is the section of the heart muscle that has been affected. If a large artery is completely closed, then the patient will face serious consequences, even death.

The symptoms of coronary heart disease are very diverse and can manifest themselves in the clinical form that they accompany. Most often, the patient is visited by the following signs of coronary heart disease:

• pain syndrome in the chest left hand or shoulder;
• heaviness behind the sternum;
• apathy and shortness of breath.

If a person has been visited by the presented symptoms or there is at least one risk factor, then the doctor is obliged to ask him about the features of the pain syndrome and about the conditions that could provoke it.

As a rule, patients are aware of their illness and can accurately describe all the causes, the frequency of seizures, the intensity of pain, their duration and nature, taking into account physical activity or taking specific medications.

Varieties of coronary heart disease

Ischemic heart disease may present various types. The classification of the disease is relevant and is used today by all doctors, despite the fact that it was developed in 1979. It presents individual forms of coronary heart disease, which are characterized by their symptoms, prognosis and therapy. Today, IHD has the following clinical forms:

1. Rapid coronary death.
2. Seizure.
3. Myocardial infarction.
4. Postinfarction cardiosclerosis.
5. Insufficient circulation.
6. Violation of the rhythm of the body.
7. Painless myocardial ischemia.
8. Microvascular ischemic heart disease.
9. New syndromes of ischemia.

Of all the described forms, most often patients are diagnosed with myocardial infarction, angina pectoris and rapid coronary death. Therefore, we will consider them in more detail.

angina pectoris

This disease is considered the most common symptom of coronary heart disease. Its development is associated with atherosclerotic damage to the vessels of the heart, resulting in blood clots and blockage of the lumen of the artery. Damaged vessels are not able to fulfill their direct duties of transferring blood, even if a person performs minor physical exertion. The result of this process is a disturbed metabolism, which is manifested by pain.

Signs of coronary heart disease in this case are as follows:

1. Pain in the chest, which has a paroxysmal character. They affect the left arm, shoulder, in some cases, the back, shoulder blade.
2. Violation of the rhythm of the heart.
3. Increase in blood pressure.
4. The occurrence of shortness of breath, feelings of anxiety, pallor of the skin.

Depending on what causes provoked angina pectoris, the following variants of its course are distinguished. She may be:

1. Tense, if it arose against the background of some kind of load. If you take nitroglycerin, then all the pain disappears.
2. Spontaneous angina pectoris is a form of coronary heart disease, which is characterized by the presence of pain without justified reasons and the absence of physical exertion.
3. Unstable angina is a form of coronary heart disease that is characterized by the progression of the disease. Here there is an increase in pain and an increased risk of acute myocardial infarction and death. The patient is increasingly using medication, as his condition has deteriorated significantly. With this form of the disease, immediate diagnosis and urgent therapy are required.

myocardial infarction

Ischemic heart disease often manifests itself in the form of myocardial infarction. Here, the necrosis of the muscle of the organ occurs due to the sudden cessation of blood supply to it. Most often, the disease affects men than women, and for the following reasons:

1. Atherosclerosis develops later in the female half of the population due to hormonal status. After the onset of menopause, there is a greater percentage of the likelihood of myocardial infarction. Already by the age of 70, the disease can affect both men and women equally.
2. Men drink more alcohol and smoke.

In addition to the risk factors presented, the following causes can contribute to the occurrence of myocardial infarction:

• violation of the coagulation and anticoagulation systems;
• insufficient development of "bypass" ways of blood circulation;
• violation of metabolism and immunity in combination with damage to the heart muscle.

This form of coronary artery disease is characterized by the death of the patient, which most often occurs in the presence of witnesses. It occurs instantly or within 6 hours from the time the heart attack occurred.

Coronary heart disease in this form is manifested by loss of consciousness, respiratory and cardiac arrest, dilated pupils. In this state of affairs, it is urgent to take therapeutic measures. If you immediately provide medical assistance to the victim, then he has a chance for life.

But, as practice shows, even timely resuscitation does not reduce the risk of death. In 80% of cases, the patient dies. This form of ischemia can affect young and old people. The reason is a sudden spasm of the coronary arteries.

Consequences of the disease

Ischemic heart disease due to untimely treatment can provoke many complications:

1. Postinfarction cardiosclerosis.
2. Chronic heart failure.
3. Acute heart failure.
4. Cardiogenic shock.

Therapeutic activities

How to treat coronary heart disease? Therapy of the disease implies a set of measures, thanks to which it is possible to normalize the delivery of the required amount of blood to the myocardium to eliminate the consequences. Therefore, the treatment of coronary heart disease involves drugs whose action is aimed at regenerating this balance.

Surgical treatment

When drug therapy has not given its positive result, the patient is prescribed surgical treatment for coronary heart disease. During the operation, the surgeon cleans the arteries from cholesterol.

There are situations when coronary heart disease occurs due to a slight hardening of platelets. Therefore, it is not possible to cite procedures such as stenting or angioplasty. If such a pathology occurs, you can try to remove a blood clot using a special medical device that looks like a drill. The effectiveness of such treatment of coronary heart disease is achieved when the vessel is affected in a separate area of ​​the artery.

Brachytherapy

Ischemic heart disease is a pathology that is actively treated today with the help of radiation. This technique is used in the case when secondary damage to the vessels of the organ occurred after angioplasty. Such treatment is prescribed when diagnosing a severe form of coronary artery disease.

The presented type of surgical therapy includes standard measures. It is advisable to carry it out when the causes of the disease are numerous blockages of the artery. The operation takes place using the blood capillaries of the internal mammary artery.

The essence of the operation is that the patient is connected to the device, thanks to which artificial blood circulation is carried out. It functions instead of the heart muscle at the time of surgery. The organ itself is forcibly stopped for a while. Such therapy is in great demand, since after it there are practically no complications. It is possible to reduce the number of side effects during open heart surgery, but it is not always possible to use such manipulation.

Minimally invasive coronary surgery

It is advisable to carry it out if the causes of IHD are blockage of the first and anterior coronary arteries. In this situation, the surgeon, instead of the damaged vessel, installs the artery that was taken from the victim from the chest. Such treatment does not involve a complete opening of the sternum.

The method of indirect myocardial revascularization with a laser

Such therapy is prescribed when surgery and angioplasty are not possible. During the operation, the heart muscle is pierced in several places using a laser. New blood vessels form at the punctured sites. The operation can be performed as a separate therapy and as a systemic approach.

Ischemic heart disease is a very serious and dangerous disease that contributes to the formation of a large number of complications, one of which is death. The success of treatment depends on the form and severity of the disease. In this case, it is very important to determine the causes of the disease and its manifestations in time.

Is everything correct in the article from a medical point of view?

Answer only if you have proven medical knowledge

Feeling pain in the heart or regular malaise associated with discomfort in the chest, we go to a cardiologist and, after going through a series of examinations, we see three mysterious letters in the line labeled "diagnosis" - IHD. What it is? Let's figure it out.

Diagnosis: ischemic heart disease

Ischemic heart disease is a damage to the walls of the myocardium caused by impaired circulatory function, which can manifest itself in both chronic and acute forms.

The history of coronary artery disease is the occurrence of an imbalance between the required level of blood supply to the heart muscle and the actually remaining coronary blood supply. Such a condition can occur if the need for blood supply has sharply increased, but it has not happened, or under normal conditions, the level of blood flow strength decreases. Then there are various changes in the myocardium due to oxygen starvation of tissues, which are characterized by the presence of: dystrophy, sclerosis or necrosis. Such conditions can be considered as an independent disease or a component of more severe forms: myocardial infarction, angina pectoris, heart failure, cardiac arrest or postinfarction cardiosclerosis.

Thus, answering the question "IHD: what is it", we can say that this is a deficiency in the blood supply to myocardial tissues, leading to its physiological changes, that is, the development of ischemia.

Causes and risk factors

In most cases, the causes of ischemia are arterial atherosclerosis of varying degrees of complexity, from the presence of plaques to complete blockage of the lumen. In this case, a disease called "angina pectoris" develops.

Also, against the background of atherosclerotic changes, spasms of the coronary arteries can occur, as a result of which the most common forms of coronary artery disease occur - this is angina pectoris, arrhythmia, hypertension.

Factors contributing to the development of this disease include:

• Arterial hypertension, which increases the chances of ischemia by 5 times.
• Hyperlipidemia causes the development of atherosclerosis and, as a consequence, ischemia.
• Smoking. Nicotine causes a stable contraction of the muscle tissue of blood vessels, impairing blood circulation throughout the body.
• Impaired carbohydrate tolerance due to diabetes mellitus.
• Obesity and physical inactivity become prerequisites for the development of ischemia.
• Heredity and old age.

Classification

"CHS: what is it?" - a question arises for a person and his relatives if such a diagnosis is made by a doctor. To understand what risks a patient has, it is necessary to refer to the WHO recommendations for identifying and systematizing the forms of the disease:

• Coronary death or cardiac arrest usually develops suddenly and is an unforeseen condition. In the event that such a patient is at a distance from other people and is not able to call for help, sudden death after a heart attack may occur.
• Angina, which is stable, post-infarction, spontaneous.
• Painless form of ischemia.
• Myocardial infarction.
• Postinfarction cardiosclerosis.
• Arrhythmia.
• Heart failure.

IHD: symptoms

Depending on the form in which ischemia develops, clinical manifestations may be different. However, as a rule, the disease is not permanent, but periodic, when states of exacerbation and total absence symptoms. Most often, patients who are diagnosed with coronary artery disease are unaware of the presence of any heart disease, since they do not feel constant ailments or any regular pain in the heart area. Therefore, the disease can develop over several years and be aggravated by other conditions of a more severe form.

With IBS, symptoms can manifest as follows:

• Pain in the region of the heart muscle, especially during physical exertion and stressful conditions.
• Pain that occurs on the left side of the body: in the back, arm, left side of the jaw.
• Shortness of breath, rapid heart rate, sensations of rhythmic failure.
• The state of general weakness, nausea, dizziness, excessive sweating.
• Puffiness in lower limbs.

It is rare that all these symptoms appear at the same time to give a complete picture of what is happening. However, any sensation of discomfort in the sternum or the presence of the above symptoms, especially with a stable or frequently recurring occurrence, should be a signal for examination for the presence of coronary artery disease in any of the forms.

Disease progression

Possible complications in ischemic disease are damage or functional changes in the state of the myocardium, which cause:

• Violations of diastolic and systolic functions.
• Development of atherosclerotic lesions.
• Violations of the contractile function of the left ventricle of the heart.
• Disorders of automatic contractility and excitability of myocardial tissues.
• Insufficient level of ergonomics and metabolism of myocardial cells.

Such changes can lead to a significant and prolonged deterioration in coronary circulation and may progress to heart failure.

IHD diagnosis

Ischemia can be detected by using various methods of instrumental observation and analysis together, as well as during the initial examination of the patient and the collection of anamnesis.

When conducting an oral survey, the cardiologist draws attention to the patient's complaints, the presence of some uncomfortable sensations in the heart area, regular descending edema in the lower extremities, as well as cyanosis of skin tissues.

Laboratory diagnostic analysis is used to study the presence of specific enzymes, the level of which increases with the occurrence of coronary artery disease, these are: creatine phosphokinase, aminotransferase, myoglobin.

Additionally, a study of the level of sugar in the blood, cholesterol, lipoproteins, triglycerides, the level of androgenic and antiandrogenic densities, nonspecific markers of cytolysis is prescribed.

The most informative and mandatory are ECG and EchoCG studies. They allow you to detect the slightest changes in the work of the myocardium, as well as visually assess the size and condition of the heart muscle, its valves, the presence of noise in the heart and its ability to contract.

In the early stages of development, when there are no pronounced symptoms that could be recorded during a survey or standard studies, such ECG studies are used when a special load is given to the heart muscle in the form exercise, helping to identify the most insignificant changes in the state of the myocardium.

Also, when the symptoms are intermittent, Holter daily ECG monitoring can be used, the essence of which is to monitor the work and condition of the heart on a portable device for one day, in order to record changes in the work of the heart. Such a study is most often used in the development of angina pectoris.

Based on the diagnosis of coronary artery disease, treatment and prevention can be prescribed both preventively, in order to prevent more severe forms, and as a rehabilitation therapy. Methods can cover both traditional and traditional medicine.

Treatment

In the course of diagnosing and identifying the diagnosis of coronary artery disease, treatment consists in using various approaches aimed at achieving the best result, these are:

• Therapy with drugs.
• Non-drug treatment.
• Carrying out coronary artery bypass surgery.
• Application of methods of angioplasty of coronary vessels.

Drug therapy for coronary artery disease consists in prescribing drugs: beta-blockers, antiplatelet agents, hypocholesterolemic agents. Diuretics, nitrates, antiarrhythmic drugs may also be prescribed.

The effect of non-drug correction on the condition consists in prescribing a special diet and dosed physical activity, herbal preparations and contrasting water procedures can also be used.

When the disease of coronary heart disease is poorly amenable to medical treatment, the question may be raised about the need for coronary artery bypass surgery or coronary angioplasty.

The method of coronary artery bypass grafting consists in the imposition of an autovenous anastomosis, bypassing the place of narrowing of the arteries, and thereby ensuring normal blood supply to the damaged area of ​​the myocardium. Coronary angioplasty is the expansion of blood vessels by placing special balloons in them and imposing frame structures that ensure normal blood flow through the lumen of the vessel.

Forecast

When a diagnosis of coronary artery disease is made, treatment is prescribed to stop further development and prevent its more severe forms. However, changes in the state of the myocardium are irreversible, and therefore any of the types of treatment will not lead to complete healing.

Prevention of coronary artery disease

As preventive measures, the most effective is the elimination of threat factors that provoke the development of the disease and compliance with a special diet, as well as exercises with moderate physical activity.

Having received an answer to the question: "IHD diagnosis, what is it?" - first of all, it is necessary to seek advice from a cardiologist and follow all his recommendations, as well as take seriously the possible consequences in the absence of treatment and preventive measures.

Ischemic heart disease is an acute or chronic myocardial injury that occurs as a result of a decrease or cessation of the supply of arterial blood to the heart muscle, which is based on pathological processes in the coronary artery system.

IHD is a widespread disease. One of the main causes of death, temporary and permanent disability worldwide. In the structure of mortality, cardiovascular diseases are in the first place, of which about 40% are accounted for by coronary artery disease.

Forms of ischemic disease

IHD classification (ICD-10; 1992)

1. angina pectoris
   • - Stable exertional angina
   • - Unstable angina
2. Primary myocardial infarction
3. Recurrent myocardial infarction
4. Old (earlier) myocardial infarction (postinfarction cardiosclerosis)
5. Sudden cardiac (arrhythmic) death
6. Heart failure (myocardial damage due to coronary artery disease)

The main reason for the disruption of myocardial oxygen supply is the mismatch between coronary blood flow and the metabolic needs of the heart muscle. This may be due to:

• - Atherosclerosis of the coronary arteries with a narrowing of their lumen by more than 70%.
• - Spasm of unchanged (little changed) coronary arteries.
• - Violations of microcirculation in the myocardium.
• - Increased activity of the blood coagulation system (or decreased activity of the anticoagulant system).

The main etiological factor in the development of coronary heart disease is atherosclerosis of the coronary arteries. Atherosclerosis develops consistently, undulating and steadily. As a result of the accumulation of cholesterol in the wall of the artery, an atherosclerotic plaque is formed. Excess cholesterol leads to an increase in plaque in size, there are obstructions to blood flow. In the future, under the influence of systemic adverse factors, the plaque is transformed from stable to unstable (cracks and ruptures occur). The mechanism of platelet activation and formation of blood clots on the surface of an unstable plaque is triggered. Symptoms aggravate with the growth of atherosclerotic plaque, gradually narrowing the lumen of the artery. A decrease in the arterial lumen area by more than 90-95% is critical, causing a decrease in coronary blood flow and deterioration of well-being even at rest.

Risk factors for coronary heart disease:

1. Gender (male)
2. Age >40-50 years
3. Heredity
4. Smoking (10 or more cigarettes per day for the last 5 years)
5. Hyperlipidemia (plasma total cholesterol > 240 mg/dL; LDL cholesterol > 160 mg/dL)
6. arterial hypertension
7. Diabetes
8. Obesity
9. Hypodynamia

Symptoms

Clinical picture of coronary artery disease

The first description of angina pectoris was offered by the English physician William Heberden in 1772: “... chest pain that occurs while walking and makes the patient stop, especially while walking shortly after eating. It seems that this pain, if it continues or intensifies, is capable of depriving a person of life; at the moment of stopping, all unpleasant sensations disappear. After the pain continues to occur for several months, it stops immediately when stopped; and in the future it will continue to arise not only when a person walks, but also when he lies ... " Symptoms usually first appear after the age of 50. In the beginning, they occur only during physical exertion.

The classic manifestations of coronary heart disease are:

• - Pain behind the sternum, often radiating to lower jaw, neck, left shoulder, forearm, hand, back.
• - The pain is pressing, squeezing, burning, suffocating. The intensity is different.
• - Provoked by physical or emotional factors. At rest, they stop on their own.
• - Lasts from 30 seconds to 5-15 minutes.
• - Rapid effect of nitroglycerin.

Treatment of coronary heart disease

Treatment is aimed at restoring normal blood supply to the myocardium and improving the quality of life of patients. Unfortunately, purely therapeutic methods of treatment are not always effective. There are many surgical methods of correction, such as coronary artery bypass grafting, transmyocardial laser myocardial revascularization and percutaneous coronary interventions (balloon angioplasty, coronary artery stenting).

The "gold standard" in the diagnosis of obstructive lesions of the coronary arteries of the heart is considered selective coronary angiography. It is used to find out whether the narrowing of the vessel is significant, which arteries and how many of them are affected, in what place and for how long. In recent years, multislice computed tomography (MSCT) with intravenous bolus contrast has become increasingly popular. In contrast to selective coronary angiography, which is essentially an x-ray surgical intervention on the arterial bed, and is performed only in a hospital setting, MSCT of the coronary arteries is usually performed on an outpatient basis using intravenous administration of a contrast agent. Another fundamental difference may be that selective coronary angiography shows the lumen of the vessel, and MSCT and the lumen of the vessel, and, in fact, the vessel wall, in which the pathological process is localized.

Depending on the changes in the coronary vessels detected during coronary angiography, various methods of treatment can be offered:

Coronary artery bypass grafting is an operation that has been practiced for many years, in which the patient's own vessel is taken and sutured to the coronary artery. This creates a bypass route for the affected area of ​​the artery. Blood in a normal volume enters the myocardium, which leads to the elimination of ischemia and the disappearance of angina attacks. CABG is the method of choice for a number of pathological conditions, such as diabetes mellitus, stem disease, multivessel disease, etc. The operation can be performed with cardiopulmonary bypass and cardioplegia, on a beating heart without cardiopulmonary bypass, and on a beating heart with cardiopulmonary bypass. Both veins and arteries of the patient can be used as shunts. The final decision on the choice of one or another type of operation depends on the specific situation and the equipment of the clinic.

Popular at the time, balloon angioplasty has lost its relevance. The main problem is the short-term effect of the performed X-ray surgery.

A more reliable and, at the same time, minimally invasive method of restoring and maintaining a normal vessel lumen is stenting. The method is essentially the same as balloon angioplasty, but a stent (a small transformable metal mesh frame) is mounted on the balloon. When introduced into the narrowing site, the balloon with the stent is inflated to the normal diameter of the vessel, the stent is pressed against the walls and retains its shape permanently, leaving the lumen open. After the stent is installed, the patient is prescribed long-term antiplatelet therapy. During the first two years, control coronary angiography is performed annually.

In severe cases of obliterating atherosclerosis of the coronary arteries, when there are no conditions for CABG and X-ray surgical interventions, the patient may be offered transmyocardial laser myocardial revascularization. In this case, the improvement of myocardial circulation occurs due to the flow of blood directly from the cavity of the left ventricle. The surgeon places a laser on the affected area of ​​the myocardium, creating many channels with a diameter of less than 1 millimeter. The channels promote the growth of new blood vessels through which blood enters the ischemic myocardium, providing it with oxygen. This operation can be performed both independently and in combination with coronary artery bypass grafting.

After the elimination of aortocoronary stenosis, the quality of life significantly improves, working capacity is restored, the risk of myocardial infarction and sudden cardiac death is significantly reduced, and life expectancy increases.

Currently, the diagnosis of coronary artery disease is not a sentence, but a reason for active action to choose the best treatment tactics that will save lives for many years.

3. TREATMENT

3.1. General principles

The basis for the treatment of chronic coronary artery disease is the modification of avoidable risk factors and complex drug therapy. As a rule, they are carried out indefinitely.

Non-drug methods of treatment include surgical revascularization of the myocardium: coronary bypass grafting and balloon angioplasty with stenting of the coronary arteries. The decision on the choice of surgical treatment is made by the attending physician, X-ray endovascular surgeon and cardiovascular surgeon, taking into account the total risk of complications, the state of the myocardium and coronary arteries, the desire of the patient and the capabilities of the medical institution.

3.2. Modifiable risk factors and training

3.2.1 Information and education

This is a necessary component of treatment, since a properly informed and trained patient carefully follows medical recommendations and can make important decisions independently.

The patient is told in an accessible form about the essence of coronary artery disease and the features of the clinical form of the disease identified in him. It should be emphasized that with due observance of medical recommendations, the symptoms of the disease can be controlled, thus improving the quality and duration of life and maintaining working capacity.

It is necessary to discuss with the patient the prospects for medical and surgical treatment of the form of coronary artery disease identified in him, as well as to stipulate the need and frequency of further instrumental and laboratory studies.

Patients are told about the typical symptoms of the disease, they are taught to correctly take planned and emergency drug therapy for the prevention and relief of angina attacks. Be sure to tell the patient about the possible side effects drugs prescribed to him and possible drug interactions.

They also talk about the indications for an emergency call for an ambulance and an appointment with a doctor at a polyclinic. Remind them to keep fast-acting nitroglycerin (tablets or aerosol) with them at all times, and to regularly replace expired drugs with fresh ones. The patient should keep the recorded ECG at home for comparison with subsequent records. It is also useful to keep at home copies of extracts from hospitals and sanatoriums, the results of studies and a list of previously prescribed medicines.

In a conversation with the patient, one should talk about the most typical symptoms of unstable angina pectoris, acute myocardial infarction and emphasize the importance of promptly seeking help when they appear.

In the event of an acute coronary syndrome, the patient should have a clear plan of action, including:

• Immediate aspirin and nitroglycerin (better in a sitting position);
• How to seek emergency medical care;
• Address and phone numbers of the nearest medical hospital with 24-hour cardiology service.

3.2.2 Smoking cessation

Smoking cessation in patients with coronary artery disease is one of the tasks of the attending physician. Studies have shown that even the simple advice of a doctor, in many cases, helps the patient to stop smoking. To help the patient cope with bad habit the doctor should:

• ask about smoking experience;
• assess the degree of nicotine dependence and the patient's desire to quit smoking;
• help the patient make a plan to stop smoking (if necessary, do this together with him);
• discuss with the patient the dates and timing of follow-up visits;
• if necessary, invite close relatives of the patient and have a conversation with them in order to ensure the support of family members in stopping smoking.

In the absence of the effect of explanatory work, nicotine replacement therapy can be applied. The drugs bupropion (wellbitrin, zyban) and varenicline used to treat nicotine addiction are considered effective and relatively safe when administered to patients with coronary artery disease, but varenicline can provoke an exacerbation of angina pectoris.

3.2.3 Diet and weight control.

The main goal of diet therapy for coronary artery disease is to reduce excess weight and the concentration of total cholesterol in plasma. Basic dietary requirements: 1) energy value up to 2000 kcal/day; 2) the content of total cholesterol up to 300 mg/day; 3) providing at the expense of fats no more than 30% of the energy value of food. A strict diet can achieve a decrease in the level of plasma total cholesterol by 10-15%. To reduce hypertriglyceridemia, enrichment of the diet with fatty fish or N-3 polyunsaturated fatty acids in food supplements at a dose of 1 g / day can be recommended.

Alcohol consumption is limited to moderate doses (50 ml of ethanol per day). Alcohol consumption in large doses (both regular and occasional) can lead to serious complications. With concomitant heart failure, diabetes mellitus and arterial hypertension, alcohol is recommended to be avoided.

Obesity and overweight are associated with an increased risk of death in patients with SS. The degree of overweight (BW) is assessed by the Quetelet index (BMI): BMI = body weight (kg) / height (m)2. Weight correction in patients suffering, along with coronary artery disease, obesity and overweight, is accompanied by a decrease in blood pressure, normalization of lipid and sugar levels in the blood. Treatment is recommended to begin with the appointment of a diet that has the following features:

• maintaining a balance between the energy consumed with food and the energy expended in daily activities;
• limiting fat intake;
• limiting alcohol consumption (for example, 100 g of vodka contains 280 kcal; in addition, alcohol consumption “disinhibits” the food reflex, simply put, it significantly increases appetite);
• restriction, and in some cases, exclusion of easily digestible carbohydrates (sugar); the proportion of carbohydrates should be 50-60% of the daily calorie content, mainly due to vegetables and fruits with a restriction of potatoes and fruits with a high glucose content - grapes, raisins, melons, pears, sweet plums, apricots, bananas;
• limited consumption of sweets, sweet non-alcoholic drinks, hot spices, spices;

Diet therapy aimed at reducing body weight is carried out under the supervision of a doctor, taking into account medical indications and contraindications. The rate of weight loss should be 0.5-1 kg per week. Pharmacotherapy of obesity is prescribed for MT index ≥30 and diet ineffectiveness, and is usually carried out in specialized hospitals.

One of the main difficulties in the treatment of obesity is maintaining the achieved result in weight loss. Therefore, weight loss is not a “one-time” measure, but the formation of motivation aimed at maintaining the achieved result throughout life.

In any programs aimed at reducing body weight, an important place is given to physical activity, which is recommended in combination with diet therapy, but always after consulting a doctor.

Obesity is often combined with a condition such as sleep apnea - stopping breathing during sleep. Patients suffering from sleep apnea have an increased risk of developing severe complications of coronary artery disease and coronary death. Today, there are methods for treating sleep apnea using the CPAP therapy (from the English. Constant Positive Airway Pressure, CPAP), during which a constant positive pressure is created in the patient's airways, which prevents respiratory arrest during sleep. If a patient with coronary artery disease and overweight is diagnosed with sleep apnea, it is recommended to refer him to a medical institution where CPAP therapy is performed.

3.2.4 Physical activity

The patient is informed about the permissible physical activity. It is very useful to learn how to compare the maximum heart rate during an exercise test (if it was carried out) with the heart rate during everyday physical exertion. Information about dosed physical activity is especially important for people restoring motor activity after myocardial infarction. In the post-infarction period, physical rehabilitation carried out by specialists is safe and improves the quality of life. Patients with angina pectoris are recommended to take nitroglycerin before the expected physical activity - this often avoids an anginal attack.

Particularly useful dosed physical activity for patients with obesity and diabetes, because. against the background of physical exercise, they improve carbohydrate and lipid metabolism.

All patients diagnosed with coronary artery disease (with the permission of the attending physician) are recommended to walk daily at an average pace of 30-40 minutes.

3.2.5 Sexual activity

Sexual activity is associated with a load of up to 6 METs depending on the type of activity. Thus, with intimacy in patients with coronary artery disease, due to sympathetic activation due to an increase in heart rate and blood pressure, conditions may arise for the development of an anginal attack with the need to take nitroglycerin. Patients should be informed about this and be able to prevent an attack of angina pectoris by taking antianginal drugs.

Erectile dysfunction is associated with many cardiac risk factors and is more common in patients with CAD. A common link between erectile dysfunction and CAD is endothelial dysfunction and antihypertensive therapy, especially beta-blockers and thiazide diuretics, which increase erectile dysfunction.

Lifestyle modification (weight loss; physical activity; smoking cessation) and pharmacological interventions (statins) reduce erectile dysfunction. Patients with erectile dysfunction, after consulting a doctor, can use phosphodiesterase type 5 inhibitors (sildenafil, vardanafil, tardanafil), taking into account exercise tolerance and contraindications - taking nitrates in any form, low blood pressure, low tolerance to physical activity. Patients at low risk of complications can generally receive this treatment without further assessment by exercise testing. Phosphodiesterase type 5 inhibitors are not recommended in patients with low BP, CHF (NYHA III-IV FC), refractory angina, and a recent cardiovascular event.

3.2.6 Correction of dyslipidemia

Correction of dyslipidemia has importance to prevent complications of coronary artery disease and coronary death. Along with the diet, dyslipidemia is treated with lipid-lowering drugs, of which the most effective are cholesterol synthesis inhibitors - statins. This has been proven in numerous studies in patients with various manifestations of coronary artery disease. A detailed presentation of issues related to the diagnosis and treatment of dyslipidemia is presented in the V version of the Russian recommendations [2].

In patients with coronary artery disease, statin therapy should be started regardless of the level of total cholesterol and LDL cholesterol. The target level of lipid-lowering therapy is estimated by the level of LDL cholesterol and is 1.8 mmol/l. or the level of cholesterol not associated with HDL-C (TC-HDL-C), which is In cases where the target level, for various reasons, cannot be achieved, it is recommended to reduce the values ​​of LDL-C or cholesterol not associated with HDL-C by 50% of the initial . As a rule, the desired result can be achieved with the help of monotherapy with one of the statins, however, in some cases, it is necessary to resort to combination therapy (with intolerance to medium or high doses of statins). Ezetimibe is usually added to statin therapy to further lower LDL-C.

Other drugs that correct lipid disorders and are registered in Russia include fibrates, nicotinic acid, and omega-3 PUFAs. Fibrates are prescribed to patients with severe hypertriglyceridemia, mainly for the prevention of pancreatitis. It has been shown that in patients with type II diabetes, the appointment of fenofibrate to persons with increased level TG and low levels of HDL-C leads to a decrease in cardiovascular complications by 24%, which is the basis for recommending fenofibrate in this category of patients. Omega 3 PUFAs at a dose of 4-6 g have a hypotriglyceridemic effect and are a second-line agent after fibrates for the correction of hypertriglyceridemia. Nicotinic acid, as well as bile acid sequestrants, in dosage form, acceptable for the correction of dyslipidemia, are currently absent on the pharmaceutical market of the Russian Federation.

It has been shown that the administration of atorvastatin at a dose of 80 mg before percutaneous coronary angioplasty with stenting prevents the development of MI during and immediately after the procedure.

In cases where lipid-lowering therapy is not effective, extracorporeal therapy (plasmapheresis, cascade plasma filtration) can be resorted to, especially in patients with coronary artery disease that developed against the background of hereditary hyperlipidemia or in patients with intolerance to drug therapy.

3.2.7 Arterial hypertension

Elevated blood pressure is the most important risk factor for the development of atherosclerosis and complications of coronary artery disease. The main goal of treating patients with AH is defined in the National Guidelines of the VNOK and RMOAG [1] and is to minimize the risk of developing CVD and death from them.

In the treatment of patients with coronary artery disease and hypertension, the level of blood pressure should be less than 140/90 mm Hg.

3.2.8. Disorders of carbohydrate metabolism, diabetes mellitus.

Disturbance of carbohydrate metabolism and DM increase the risk of CVD in men by 3 times, in women by 5 times compared with people without diabetes. Diagnosis and treatment of diabetes are discussed in special guidelines. In this category of patients, the control of the main risk factors, including blood pressure, dyslipidemia, overweight, low physical activity, smoking, should be carried out with particular care:

Blood pressure should be below 140/90 mmHg. Due to the fact that in patients with diabetes there is a real threat of kidney damage, they are shown ACE inhibitors or angiotensin II receptor antagonists to correct blood pressure.

Statins are the main treatment for hypercholesterolemia. At the same time, in patients with hypertriglyceridemia and low levels of HDL cholesterol (<0,8 ммоль/л) возможно добавление к статинам фенофибрата (см предыдущий раздел).

With regard to glycemic control, it is currently recommended to focus on the target level of glycated hemoglobin HbAIc, taking into account the duration of the course of the disease, the presence of complications, and age. The main benchmarks for estimating the HbAIc target level are presented in Table 2.

Table 2. Algorithm for individual selection of the target HbAIc level depending on the characteristics of the course of diabetes and the age of the patient.

HbA1c* – glycated hemoglobin

In patients with chronic coronary artery disease, in combination with type I and II diabetes and manifestations of chronic renal failure (GFR> 60-90 ml / min / 1.73 m²), the appointment of statins is not associated with any side effects. However, with more severe CKD (GFR

3.2.9 Psychosocial factors

Patients with coronary artery disease often have anxiety and depressive disorders; many of them are exposed to stress factors. In the case of clinically significant disorders, IHD patients should be consulted with specialists. Antidepressant therapy significantly reduces symptoms and improves quality of life, but there is currently no strong evidence that such treatment reduces the risk of cardiovascular events.

3.2.10 Cardiac rehabilitation

It is usually performed among recent MI or after invasive interventions. It is recommended for all patients diagnosed with coronary artery disease, including those suffering from stable angina pectoris. There is evidence that regular exercise testing in a cardiac rehabilitation program, both in specialized centers and at home, has an effect on overall and cardiovascular mortality, as well as the number of hospitalizations. Less proven beneficial effect on the risk of MI and the need for myocardial revascularization procedures. There is evidence of improved quality of life with cardiac rehabilitation.

3.2.11 Influenza vaccination

Annual seasonal influenza vaccination is recommended for all patients with coronary artery disease, especially the elderly (in the absence of absolute contraindications).

3.2.12 Hormone replacement therapy

The results of large randomized trials not only failed to support the hypothesis of a beneficial effect of estrogen replacement therapy, but also indicated an increased risk cardiovascular disease in women over 60 years of age. Currently, hormone replacement therapy is not recommended for either primary or secondary prevention of cardiovascular disease.

3.3. Medical treatment

3.3.1 Drugs that improve the prognosis in chronic coronary artery disease:

• Antiplatelet (acetylsalicylic acid, clopidogrel);
• statins;
• Blockers of the renin-angiotensin-aldosterone system.

3.3.1.1. Antiplatelet agents

Antiplatelet drugs inhibit platelet aggregation and prevent the formation of blood clots in the coronary arteries, however, antiplatelet therapy is associated with an increased risk of hemorrhagic complications.

Aspirin. In most patients with stable coronary artery disease, low-dose aspirin is preferred due to the favorable benefit/risk ratio and low cost of treatment. Aspirin remains the mainstay of drug prevention of arterial thrombosis. The mechanism of action of aspirin is the irreversible inhibition of cyclooxygenase-1 platelets and disruption of thromboxane synthesis. Complete suppression of thromboxane production is achieved with continuous long-term use of aspirin at doses ≥ 75 mg per day. The damaging effect of aspirin on gastrointestinal tract increases as the dose increases. The optimal balance of benefit and risk is achieved with the use of aspirin in the dose range from 75 to 150 mg per day.

Blockers of P2Y12 platelet receptors. Platelet P2Y12 receptor blockers include thienipyridines and ticagrelor. Thienopyridines irreversibly inhibit ADP-induced platelet aggregation. The evidence base for the use of these drugs in patients with stable coronary artery disease was the CAPRIE study. In this study, which included high-risk patients (recent myocardial infarction, stroke, and intermittent claudication), clopidogrel was more effective and had a better safety profile than aspirin at a dose of 325 mg in terms of preventing vascular complications. Subgroup analysis showed benefits of clopidogrel only in patients with atherosclerotic lesions of peripheral arteries. Therefore, clopidogrel should be considered a second-line drug for aspirin intolerance or as an alternative to aspirin in patients with advanced atherosclerotic disease.

Third generation thienopyridine - prasugrel, as well as a drug with a reversible mechanism of P2V12 receptor blockade - ticagrelor cause a stronger inhibition of platelet aggregation compared to clopidogrel. These drugs are more effective than clopidogrel in the treatment of patients with acute coronary syndromes. There have been no clinical studies of prazugrel and ticagrelor in patients with stable CAD.

Dual antiplatelet therapy. Combination antiplatelet therapy, including aspirin and thienopyridine (clopidogrel), is the standard of care for patients who survived ACS, as well as for patients with stable CAD undergoing elective percutaneous coronary interventions (PCI).

In a large study including stable patients with atherosclerotic lesions of various vascular beds or multiple cardiovascular risk factors, the addition of clopidogrel to aspirin did not provide additional benefit. A subgroup analysis of this study found a positive effect of the combination of aspirin and clopidogrel only in patients with coronary artery disease who had a myocardial infarction.

Thus, dual antiplatelet therapy has advantages only in certain categories of patients with a high risk of ischemic events. Routine use of this therapy in patients with stable CAD is not recommended.

Residual platelet reactivity and pharmacogenetics of clopidogrel. The fact of the variability of indicators characterizing the residual reactivity of platelets (RRT) during treatment with antiplatelet drugs is well known. In this regard, the possibility of adjusting antiplatelet therapy based on the results of the study of platelet function and the pharmacogenetics of clopidogrel is of interest. It has been established that high ORT is determined by many factors: gender, age, the presence of ACS, diabetes, as well as increased consumption of platelets, concomitant use of other drugs and low adherence of patients to treatment.

Specific for clopidogrel is the carriage of single nucleotide polymorphisms associated with a decrease in the absorption of the drug in the intestine (ABCB1 C3435T gene), or its activation in the liver (CYP2C19 * 2 gene). The influence of the carriage of these genetic variants on the outcomes of treatment with clopidogrel has been proven for patients with ACS undergoing invasive treatment; there are no similar data for patients with stable CAD. Therefore, a routine study of the pharmacogenetics of clopidogrel and the evaluation of ORT in patients with stable coronary artery disease, incl. undergoing planned PCI are not recommended.

Preparations:

• Acetylsalicylic acid inside at a dose of 75-150 mg 1 r / day
• Clopidogrel orally at a dose of 75 mg 1 r / day.

3.3.1.2. Statins and other lipid-lowering drugs

The reduction in blood cholesterol levels is accompanied by a significant population reduction in overall mortality and the risk of all cardiovascular complications. Long-term lipid-lowering therapy is mandatory for all forms of coronary artery disease - against the background of a strict lipid-lowering diet (see above).

Patients with proven CAD are at very high risk; they should be treated with statins according to the 2012 National Atherosclerosis Society (NOA) guidelines for the treatment of dyslipidemia. Target LDL-C<1,8 ммоль/л (<70 мг/дл) или на >50% of the original level. For these purposes, high doses of statins are often used - atorvastatin 80 mg or rosuvastatin 40 mg. Other lipid-lowering drugs (fibrates, nicotinic acid, ezetimibe) can reduce LDL-C, but there is currently no clinical evidence that this is accompanied by an improved prognosis.

3.3.1.3. Blockers of the renin-angiotensin-aldosterone system

ACE inhibitors reduce overall mortality, the risk of MI, stroke, and CHF in patients with heart failure and complicated diabetes. The appointment of ACE inhibitors should be discussed in patients with chronic coronary artery disease, especially with concomitant hypertension, left ventricular ejection fraction equal to or less than 40%, diabetes, or chronic kidney disease, if they are not contraindicated. It should be noted that not all studies have demonstrated the effects of ACE inhibitors in reducing the risk of death and other complications in patients with chronic coronary artery disease with preserved left ventricular function. The ability of perindopril and ramipril to reduce the combined risk of complications in a general sample of patients with chronic coronary artery disease during long-term treatment was reported. In patients with chronic coronary artery disease with hypertension, combination therapy with an ACE inhibitor and a dihydropyridine calcium antagonist, such as perindopril/amlodipine or benazepril/amlodipine, has been shown to be effective in long-term clinical studies. The combination of ACE inhibitors and angiotensin receptor blockers is not recommended as it is associated with increased adverse events without clinical benefit.

In case of intolerance to ACE inhibitors, angiotensin receptor blockers are prescribed, but there is no clinical evidence of their effectiveness in patients with chronic coronary artery disease.

Preparations:

• Perindopril orally at a dose of 2.5-10 mg 1 r / day;
• Ramipril inside at a dose of 2.5-10 mg 1 r / day;

3.3.2. Drugs that improve the symptoms of the disease:

• Beta-blockers;
• calcium antagonists;
• Nitrates and nitrate-like agents (molsidomine);
• Ivabradin;
• Nicorandil;
• Ranolazine;
• Trimetazidine

Since the main goal of treating chronic coronary artery disease is to reduce morbidity and mortality, then in any drug therapy regimen in patients with organic lesions of the coronary arteries and myocardium, drugs with a proven positive effect on the prognosis in this disease must be present - unless a particular patient has direct contraindications to their acceptance.

3.3.2.1 Beta blockers

Drugs of this class have a direct effect on the heart through a decrease in heart rate, myocardial contractility, atrioventricular conduction and ectopic activity. Beta-blockers are the main tool in the treatment regimen for patients with coronary artery disease. This is due to the fact that drugs of this class not only eliminate the symptoms of the disease (angina pectoris), have an anti-ischemic effect and improve the quality of life of the patient, but can also improve the prognosis after myocardial infarction and in patients with low left ventricular ejection fraction and CHF. It is assumed that beta-blockers may have a protective effect in patients with chronic coronary artery disease with preserved left ventricular systolic function, but there is no evidence from controlled studies to this point of view.

For the treatment of angina pectoris, BAB is prescribed at a minimum dose, which, if necessary, is gradually increased until complete control of angina attacks or the maximum dose is reached. When using BAB, the maximum reduction in myocardial oxygen demand and an increase in coronary blood flow is achieved at a heart rate of 50-60 bpm. If side effects occur, it may be necessary to reduce the dose of BAB or even cancel them. In these cases, other rhythm-lowering drugs, such as verapamil or ivabradine, should be considered. The latter, unlike verapamil, can be added to BB if necessary to improve heart rate control and increase anti-ischemic efficacy. For the treatment of angina pectoris, the most commonly used BBs are bisoprolol, metoprolol, atenolol, nebivolol, and carvedilol. The drugs are recommended in the following doses:

• Bisoprolol inside 2.5-10 mg 1 r / day;
• Metoprolol succinate inside 100-200 mg 1 r / day;
• Metoprolol tartrate inside 50-100 mg 2 r / day (not recommended for CHF);
• Nebivolol inside 5 mg 1 r / day;
• Carvedilol inside 25-50 mg 2 r / day;
• Atenolol inside starting with 25-50 mg 1 r / day, the usual dose is 50-100 mg (not recommended for CHF).

With insufficient effectiveness, as well as the inability to use a sufficient dose of BBs due to undesirable manifestations, it is advisable to combine them with nitrates and/or calcium antagonists (long-acting dihydropyridine derivatives). If necessary, ranolazine, nicorandil and trimetazidine can be added to them.

3.3.2.2. calcium antagonists

Calcium antagonists are used to prevent angina attacks. The antianginal efficacy of calcium antagonists is comparable to BB. Diltiazem and, especially verapamil, to a greater extent than dihydropyridine derivatives, act directly on the myocardium. They reduce heart rate, inhibit myocardial contractility and AV conduction, and have an antiarrhythmic effect. In this they are similar to beta-blockers.

Calcium antagonists show the best results in the prevention of ischemia in patients with vasospastic angina. Calcium antagonists are also prescribed in cases where BBs are contraindicated or not tolerated. These drugs have a number of advantages over other antianginal and antiischemic drugs and can be used in a wider range of patients with comorbidities than BB. The drugs of this class are indicated for the combination of stable angina pectoris with hypertension. Contraindications include severe arterial hypotension; severe bradycardia, weakness of the sinus node, impaired AV conduction (for verapamil, diltiazem); heart failure (except amlodipine and felodipine);

Preparations:

• Verapamil inside 120-160 mg 3 r / day;
• Verapamil of prolonged action 120-240 mg 2 r / day;
• Diltiazem inside 30-120 mg 3-4 r / day
• Diltiazem long-acting oral 90-180 mg 2 r / day or 240-500 mg 1 r / day.
• Long-acting nifedipine orally 20-60 mg 1-2 r / day;
• Amlodipine inside 2.5-10 mg 1 r / day;
• Felodipine inside 5-10 mg 1 r / day.

3.3.2.3. Nitrates and nitrate-like agents

For the treatment of IHD, nitrates are traditionally widely used, which give an undoubted clinical effect, can improve the quality of life and prevent complications of acute myocardial ischemia. The advantages of nitrates include a variety of dosage forms. This allows patients with different severity of the disease to use nitrates for both relief and prevention of angina attacks.

Relief of an attack of angina pectoris. If angina occurs, the patient should stop, sit down, and take a short-acting NTG or ISDN. The effect occurs 1.5-2 minutes after taking the pill or inhalation and reaches a maximum after 5-7 minutes. At the same time, pronounced changes in peripheral vascular resistance occur due to the expansion of veins and arteries, the stroke volume of the heart and systolic blood pressure decrease, the ejection period shortens, the volume of the heart ventricles decreases, coronary blood flow and the number of functioning collaterals in the myocardium increase, which ultimately ensures the restoration of the necessary coronary blood flow and the disappearance of the focus of ischemia. Favorable changes in hemodynamics and vascular tone persist for 25-30 minutes - a time sufficient to restore the balance between myocardial oxygen demand and its supply with the coronary blood flow. If the attack is not stopped within 15-20 minutes, including after repeated administration of nitroglycerin, there is a threat of developing MI.

Isosorbide trinitrate (nitroglycerin, NTG) and some forms of isosorbide dinitrate (ISDN) are indicated for the relief of an angina attack. These short-acting drugs are used in sublingual and aerosol dosage forms. The effect develops more slowly (begins after 2-3 minutes, reaches a maximum after 10 minutes), but it does not cause the “steal” phenomenon, affects heart rate less, less often causes headache, dizziness, nausea, and to a lesser extent affects the level of blood pressure. With sublingual administration of ISDN, the effect can persist for 1 hour:

Preparations:

• Nitroglycerin 0.9-0.6 mg sublingually or inhaled 0.2 mg (2 valve strokes)
• Isosorbide dinitrate inhalation 1.25 mg (two valve presses)
• Isosorbide dinitrate sublingually 2.5-5.0 mg.

Every patient with coronary artery disease should always have fast-acting NTG with him. It is recommended to take it immediately if an angina attack does not stop with the exclusion of provoking factors (physical activity, psycho-emotional stress, cold). In no case can you expect an independent cessation of an angina attack. In the absence of effect, the intake of NG can be repeated after 5 minutes, but not more than 3 times in a row. If the pain persists, you must urgently call an ambulance or actively seek medical attention.

Prevention of an angina attack

For long-term maintenance of a sufficient concentration in the blood, isosorbide dinitrate or isosorbide mononitrate are used, which are the drugs of choice:

Preparations:

• Isosorbide dinitrate inside 5-40 mg 4 r / day
• Isosorbide dinitrate long-acting oral 20-120 mg 2-3 r / day
• Isosorbide mononitrate inside 10-40 mg 2 r / day
• Isosorbide mononitrate long-acting orally 40-240 mg 1 r / day

When prescribing nitrates, it is necessary to take into account the time of onset and duration of their antianginal action in order to protect the patient during periods of greatest physical and psycho-emotional stress. The dose of nitrates is selected individually.

Nitrates can be applied in the form of transdermal forms: ointments, patches and discs.

• Nitroglycerin 2% ointment, apply 0.5-2.0 cm on the skin of the chest or left arm
• Nitroglycerin patch or disc 10, 20 or 50 mg attached to the skin for 18-24 hours

The onset of the therapeutic effect of the ointment with NTG occurs on average after 30-40 minutes and lasts 3-6 hours. Significant individual differences in the effectiveness and tolerability of the drug should be taken into account, depending on the characteristics and condition of the skin, blood circulation in it and the subcutaneous layer, as well as on temperature environment. The antianginal effect of nitrates in the form of discs and patches occurs on average 30 minutes after application and lasts for 18, 24 and 32 hours (in the last two cases, tolerance may develop quite quickly).

Nitroglycerin is also used in the so-called buccal dosage forms:

• Nitroglycerin attach to the oral mucosa a polymer film 1 mg or 2 mg

When sticking a film with NTG on the oral mucosa, the effect occurs after 2 minutes and lasts 3-4 hours.

Nitrate tolerance and withdrawal syndrome. Weakening of sensitivity to nitrates often develops with prolonged use of long-acting drugs or transdermal dosage forms. Tolerance is individual in nature and does not develop in all patients. It can manifest itself either in a decrease in the anti-ischemic effect, or in its complete disappearance.

For the prevention of tolerance to nitrates and its elimination, intermittent intake of nitrates during the day is recommended; taking nitrates of medium duration of action 2 r / day, prolonged action - 1 r / day; alternative therapy with molsidomine.

Molsidomin is close to nitrates in terms of the mechanism of antianginal action, but does not exceed them in effectiveness, it is prescribed for nitrate intolerance. It is usually prescribed to patients with contraindications to the use of nitrates (with glaucoma), with poor tolerance (severe headache) of nitrates or tolerance to them. Molsidomine combines well with other antianginal drugs, primarily with BB.

• Molsidomin orally 2 mg 3 r/day
• Molsidomin prolonged action inside 4 mg 2 r / day or 8 mg 1 r / day.

3.3.2.4. sinus node inhibitor ivabradine

At the heart of its antianginal action of ivabradine is a decrease in heart rate through selective inhibition of the transmembrane ion current If in the cells of the sinus node. Unlike BB, ivabradine reduces only heart rate, does not affect myocardial contractility, conduction and automatism, as well as blood pressure. The drug is recommended for the treatment of angina pectoris in patients with stable angina pectoris in sinus rhythm with contraindications / intolerance to taking BB or together with BB with insufficient antianginal effect. It has been shown that the addition of the drug to a BB in patients with coronary artery disease with a reduced left ventricular ejection fraction and a heart rate of more than 70 beats/min improves the prognosis of the disease. Ivabradin is administered orally 5 mg 2 r / day; if necessary, after 3-4 weeks, the dose is increased to 7.5 mg 2 r / day

3.3.2.5. Potassium channel activator nicorandil

The antianginal and anti-ischemic drug nicorandil simultaneously has the properties of organic nitrates and activates ATP-dependent potassium channels. Expands coronary arterioles and veins, reproduces the protective effect of ischemic preconditioning, and also reduces platelet aggregation. Long-term use of the drug may contribute to the stabilization of atherosclerotic plaque, and in one study reduced the risk of cardiovascular complications. Nicorandil does not cause the development of tolerance, does not affect blood pressure, heart rate, conduction and myocardial contractility. It is recommended for the treatment of patients with microvascular angina (with the ineffectiveness of BB and calcium antagonis). The drug is used both for stopping and for preventing angina attacks.

A drug:

• Nicorandil under the tongue 20 mg for the relief of angina attacks;
• Nicorandil inside 10-20 mg 3 r / day for the prevention of angina pectoris.

3.3.2.6. Ranolazine

Selectively inhibits late sodium channels, which prevent intracellular calcium overload, a negative factor in myocardial ischemia. Ranolazine reduces myocardial contractility and stiffness, has an anti-ischemic effect, improves myocardial perfusion, and reduces myocardial oxygen demand. Increases the duration of physical activity before the onset of symptoms of myocardial ischemia. Does not affect heart rate and blood pressure. Ranolazine is indicated for insufficient antianginal efficacy of all major drugs.

• Ranolazine inside 500 mg 2 r / day. If necessary, after 2-4 weeks, the dose can be increased to 1000 mg 2 r / day

3.3.2.7. Trimetazidine

The drug is an anti-ischemic metabolic modulator, its anti-ischemic efficacy is comparable to propranolol 60 mg/day. Improves metabolism and energy supply of the myocardium, reduces myocardial hypoxia, without affecting hemodynamic parameters. It is well tolerated and can be administered with any other antianginal drugs. The drug is contraindicated in movement disorders (Parkinson's disease, essential tremor, muscle rigidity and "restless legs syndrome"). Has not been studied in long-term clinical studies in patients with chronic coronary artery disease.

• Trimetazidine orally 20 mg 3 times a day
• Trimetazidine inside 35 mg 2 r / day.

3.3.3. Features of drug treatment of vasospastic angina pectoris

Beta-blockers are not recommended for vasospastic angina in the presence of angiographically intact coronary arteries. For the prevention of anginal attacks, such patients are prescribed calcium antagonists, for the relief of attacks, it is recommended to take NTG or ISDN according to the general rules.

In cases where spasm of the coronary arteries occurs against the background of stenosing atherosclerosis, it is advisable to prescribe small doses of BAB in combination with calcium antagonists. The prognostic effect of ASA, statins, ACE inhibitors in vasospastic angina against the background of angiographically intact coronary arteries has not been studied.

3.3.4. Features of drug treatment of microvascular angina pectoris

With this form of angina, the appointment of statins and antiplatelet agents is also recommended. To prevent pain syndromes, BBs are primarily prescribed, and with insufficient effectiveness, calcium antagonists and long-acting nitrates are used. In cases of persistent angina pectoris, ACE inhibitors and nicorandil are prescribed. There are data on the effectiveness of ivabradine and ranolazine.

3.4. Non-drug treatment

3.4.1. Myocardial revascularization in chronic ischemic heart disease

Planned myocardial revascularization is performed using balloon angioplasty with coronary artery stenting, or by coronary artery bypass grafting.

In each case, when deciding on revascularization for stable angina, the following should be considered:

1. The effectiveness of drug therapy. If, after the appointment of a combination of all antianginal drugs in optimal doses, the patient continues to have angina attacks with an unacceptable frequency for this particular patient, revascularization should be considered. It should be emphasized that the effectiveness of drug therapy is a subjective criterion and must necessarily take into account the individual lifestyle and wishes of the patient. For very active patients, even angina pectoris I FC may be unacceptable, while in patients leading a sedentary lifestyle, higher grades of angina pectoris may be quite acceptable.
2. Results of stress tests. The results of any exercise test may reveal criteria for a high risk of complications that indicate a poor long-term prognosis (Table 7).
3. risk of interference. If the expected risk of the procedure is low and the success rate of the intervention is high, this is an additional argument in favor of revascularization. The anatomical features of the CA lesion, the clinical characteristics of the patient, and the operational experience of this institution are taken into account. As a rule, an invasive procedure is withheld when the estimated risk of death during the procedure exceeds the risk of death for an individual patient within 1 year.
4. Patient preference. The issue of invasive treatment should be discussed in detail with the patient. It is necessary to tell the patient about the impact of invasive treatment not only on current symptoms, but also on the long-term prognosis of the disease, and also talk about the risk of complications. It is also necessary to explain to the patient that even after successful invasive treatment, he will have to continue taking medications.

3.4.1.1 Endovascular treatment: angioplasty and coronary artery stenting

In the vast majority of cases, balloon angioplasty of one or more segments of the coronary arteries (CA) is now accompanied by stenting. For this purpose, stents with various types of drug coatings are used, as well as stents without drug coating.

Stable angina is one of the most common indications for referral to BCA. At the same time, it should be clearly understood that the main goal of BCA in these cases should be considered to be a decrease in the frequency or disappearance of pain attacks (angina pectoris).

Indications for angioplasty with stenting of the coronary arteries in stable coronary artery disease:

• Angina pectoris with insufficient effect from the maximum possible drug therapy;
• Angiographically verified stenosing atherosclerosis of the coronary arteries;
• Hemodynamically significant isolated stenoses of 1-2 coronary arteries in the proximal and middle segments;

In doubtful cases, indications for CCA are clarified after an imaging stress test (stress echocardiography or exercise myocardial perfusion scintigraphy), which allows the identification of a symptom-related coronary artery.

The long-term prognosis for stable angina pectoris does not improve better than optimal drug therapy. It is important to remember that even a successful BCA with stenting and a decrease / disappearance as a result of angina symptoms cannot be considered a reason for canceling permanent drug therapy. In some cases, the "drug load" in the postoperative period may increase (due to the additional intake of antiplatelet agents).

3.4.1.2. Coronary Artery Bypass Surgery in Chronic IHD

Indications for surgical myocardial revascularization are determined by clinical symptoms, CAG and ventriculography data. Successful coronary artery bypass surgery not only eliminates the symptoms of angina pectoris and the associated improvement in quality of life, but also significantly improves the prognosis of the disease, reducing the risk of non-fatal MI and death from cardiovascular complications.

Indications for coronary artery bypass grafting in chronic coronary artery disease:

• Stenosis > 50% of the main trunk of the left coronary artery;
• Stenosis of the proximal segments of all three major coronary arteries;
• Coronary atherosclerosis of a different localization involving the proximal anterior descending and circumflex arteries;
• multiple occlusions of the coronary arteries;
• combinations of coronary atherosclerosis with left ventricular aneurysm and/or valvular disease;
• diffuse distal hemodynamically significant stenoses of the coronary arteries;
• previous ineffective angioplasty and stenting of the coronary arteries;

Decreased systolic function of the left ventricle (left ventricular ejection fraction<45%) является дополнительным фактором в пользу выбора шунтирования как способа реваскуляризации миокарда.

Significant dysfunction of the left ventricle (left ventricular ejection fraction<35%, конечное диастолическое давление в полости левого желудочка >25 mm. rt. Art.) in combination with clinically expressed heart failure significantly worsen the prognosis of both surgical and drug treatment, but are not currently considered absolute contraindications to surgery.

With isolated lesions of the coronary arteries and variants of stenoses favorable for dilatation, both shunting and angioplasty with stenting can be performed.

In patients with occlusions and multiple complicated coronary artery lesions, the long-term results of surgical treatment are better than after stenting.

Indications and contraindications for surgical treatment of IHD are determined in each specific case.

The best results of myocardial revascularization using bypass grafting were noted with the maximum use of internal thoracic arteries as bypasses under cardiopulmonary bypass and cardioplegia, using precision technology. Operations are recommended to be performed in specialized hospitals, where mortality during elective interventions in patients with an uncomplicated history is less than 1%, the number of perioperative infarcts does not exceed 1-4%, and the frequency of infectious complications in the postoperative period is less than 3%.

3.4.2. Experimental non-drug treatment of chronic coronary artery disease

Sympathectomy, epidural spinal electrical stimulation, intermittent urokinase therapy, transmyocardial laser revascularization, etc., are not widely used, the question of the possibilities of gene therapy is still open. New and actively developing non-drug methods for the treatment of chronic coronary artery disease are external counterpulsation (ECP) and extracorporeal cardiological shock wave therapy (ECWT), which are considered methods of "non-invasive cardiac revascularization".

External counterpulsation is a safe and atraumatic therapeutic method that increases the perfusion pressure in the coronary arteries during diastole and reduces the resistance to systolic cardiac output as a result of the synchronized functioning of pneumatic cuffs applied to the legs of patients. The main indication for external counterpulsation is drug-resistant angina III-IV FC with concomitant heart failure, if it is impossible to perform invasive myocardial revascularization (bypass or BCA with stenting).

Extracorporeal cardiological shock wave therapy (ECWT) is a new approach to the treatment of the most severe group of patients with chronic coronary artery disease, ischemic cardiomyopathy and heart failure, resistant to drug therapy, when it is impossible to perform invasive myocardial revascularization (bypass or BCA with stenting). The CUWT method is based on the impact on the myocardium of extracorporeally generated energy of shock waves. It is assumed that this method activates coronary angiogenesis and promotes vasodilation of the coronary arteries. The main indications for SWVT: 1) severe stable angina pectoris III-IV FC, refractory to drug treatment; 2) inefficiency of conventional methods of myocardial revascularization; 3) residual symptoms after myocardial revascularization; 4) a widespread lesion of the distal branches of the coronary arteries, 5) the preservation of the viable myocardium of the left ventricle.

The effect of these non-drug treatments, carried out within the framework of accepted protocols, is expressed in improving the quality of life: reducing the severity of angina pectoris and the need for nitrates, increasing exercise tolerance against the background of improving myocardial perfusion and hemodynamic parameters. The effect of these treatments on prognosis in chronic CAD has not been studied. The advantage of external counterpulsation and SWT methods is their non-invasiveness, safety, and the possibility of being performed on an outpatient basis. These methods are not used everywhere, they are prescribed according to individual indications in specialized institutions.

Lack of blood supply in Latin is ischemia of the heart. Blood during ischemia is simply not able to pass through the coronary arteries in the required amount due to blockage or narrowing of the latter. Therefore, the heart muscle does not receive the required amount of oxygen, and if treatment is not carried out in time, it does not contract, which, accordingly, leads to the death of the patient.

Causes

The main reasons for the narrowing of the coronary arteries are atherosclerotic plaques, which are deposited gradually on their inner surfaces, starting, by the way, from a young age. Over time, they only become more, and when the lumen of the vessel narrows to 70% without treatment, oxygen starvation of the heart muscle begins.

The removal of waste substances from cells during cardiac ischemia also becomes difficult. If the plaque completely clogs the vessel and blocks the blood flow, coronary artery disease (CHD) of the heart passes into the most acute phase - myocardial infarction develops. Another cause of cardiac ischemia, in addition to the development of atherosclerotic plaques, is an inflammatory process in the arteries or spasm.

At-risk groups

The greatest risk of ischemia is in patients with atherosclerosis or with prerequisites for its development:

• with high cholesterol;
• with hypertension and diabetes;
• eating a lot of high-calorie foods with a small amount of vegetable oils and fresh vegetables;
• overweight, smokers.

A huge role in the development of cardiac ischemia is played by unfavorable heredity and impaired metabolism, especially if the signs of the disease appear against the background of nervous strain and lack of physical activity.

How to recognize the occurrence of coronary artery disease

Usually, the initial symptoms of ischemia of the heart appear with emotional stress or physical exertion. The heart feels like something is squeezing, there is heaviness behind the sternum. The form of the disease is determined by how pronounced oxygen starvation is, how quickly it occurs and how long it lasts. In the treatment, the following types of ischemia are distinguished:

1. A silent form (asymptomatic) of ischemia, in which pain is not experienced, and heart disease is detected after examination. Usually characteristic of the early stages of ischemia, may occur immediately after a heart attack.
2. The arrhythmic form of ischemia is recognized by the occurrence of atrial fibrillation and other rhythm disturbances.
3. Angina pectoris, the symptoms of which are usually manifested by exertion of pain behind the sternum. Detailed sensations can also occur when overeating. An attack of angina pectoris is accompanied by squeezing, heaviness or even burning in the chest. Pain can also be given to the left arm, forearm, neck, teeth. Often there is suffocation, darkening of the eyes, profuse sweating and weakness.

Most angina attacks occur in the morning. These can be short manifestations of 5-10 minutes, repeated with different frequencies. It is most reliable to stop this attack by stopping any physical activity, emotional calming and taking nitroglycerin. You can use it in the absence of a result with an interval of five minutes up to three times in a row.

Angina pectoris is also divided into two types:

1. A stable, chronic form of coronary artery disease, in which attacks occur with approximately the same frequency, with equal load and for a long time have the same character.
2. A progressive form (unstable), in which the frequency of attacks increases over time, the severity may also increase.

In the latter case, the threshold of physical activity for the onset of an attack also becomes less and less, pain in the heart may not leave the patient even in the absence of any physical stress. This form of cardiac ischemia, if left untreated, often develops into myocardial infarction.

When to see a doctor

To increase the effectiveness of ischemia treatment and not bring the disease to critical stages, you should consult a doctor immediately after the first symptoms of cardiac ischemia appear:

1. At times you feel pain behind the sternum;
2. Breathing is sometimes difficult;
3. In the work of the heart you sometimes feel interruptions;
4. You can hardly endure even small physical activities like climbing stairs;
5. You have bouts of dizziness, shortness of breath, often feeling tired, sometimes fainting;
6. The heart sometimes seems to burst out of the chest for no apparent reason.

If the above symptoms occur in your case, then this is already a serious reason to contact a cardiologist or therapist for a comprehensive treatment.

Diagnosis

A complete diagnosis of cardiac ischemia involves a series of examinations:

• first of all, your pressure will be measured;
• you will need to pass blood biochemistry and a general analysis to determine the level of cholesterol in it;
• you will also need to go for an ECG - electrocardiography, as well as perform a stress test.

The last test for cardiac ischemia is carried out on a special bicycle (veloergometer) with sensors attached to the chest. While you are pedaling, a specialist cardiologist will determine at what physical load dangerous changes begin in your body.

In some cases, with ischemia, you may also be referred for an ultrasound (ultrasound) of the heart to check the work of the myocardium. The most accurate picture showing which artery and how narrowed is another study - angiography. When it is carried out, a substance is introduced into the bloodstream that makes the coronary arteries visible during an X-ray examination. As a result, the specialist determines how the blood moves through the vessels and exactly where the congestion is.

Treatment

Cardiac ischemia always develops gradually, so it is very important to identify the disease at an early stage of ischemia and start treatment. For this, a set of drugs is used:

1. For vasodilation - nitrosorbitol, nitroglycerin;
2. Preventing the formation of blood clots - heparin, aspirin;
3. Drugs to fight high cholesterol and oxygenate heart cells.

Sometimes other drugs, such as beta-blockers, are used to treat ischemia, which lowers blood pressure and slows the heart down so it needs less oxygen. In the hospital, drugs are also used that dissolve existing blood clots. Also, patients can independently use sedatives, preferably of plant origin, because it is stress that often provokes new attacks of coronary disease. You can use, for example, motherwort or valerian.

However, all of the above drugs can only slow down the development of the disease. Treatment of cardiac ischemia, especially in its severe manifestations, is possible only through surgical intervention.

Coronary artery bypass grafting

During this operation, surgeons implant a new vessel. This is a shunt, through which a sufficient amount of blood will now flow to the heart, bypassing the damaged area. As a donor vessel, the great saphenous vein of the leg is usually used, unless, however, the patient suffers from varicose veins. At one end, the vein is sutured to the aorta, while at the other, to the vessel below the constriction, after which the blood flow rushes along the artificially created channel.

After the operation, the patient's angina attacks disappear, he stops taking most of the medications, without which it was previously impossible to exist, and essentially returns to normal life. But this newly created shunt can also be blocked with cholesterol plaques over time and lead to a new development of cardiac ischemia, so the patient must also monitor the state of health.

Angioplasty

During this operation, the surgeon mechanically expands the area of ​​the narrowed artery, and blood flow is restored during ischemia. To do this, a balloon catheter in the form of a flexible tube is inserted into the femoral artery and passed into the coronary arteries.

When the tube reaches the site of narrowing of the vessel, the balloon put on the catheter is inflated and a stent is installed - a device resembling a spacer to prevent narrowing of the vessel. This operation is much easier to tolerate, but it is contraindicated in patients with diabetes and those who have an acute phase of the disease, and vascular damage is already too strong.

Prevention of coronary disease

An effective way to prevent and treat coronary heart disease is to change your lifestyle, which will eliminate the very causes of heart ischemia. The following habits will need to be changed:

1. Quit smoking;
2. Compliance with a diet that includes low-fat foods, the use of fresh vegetables, fruits;
3. Daily physical activity, exercise therapy, gradually reduce body weight;
4. Monitor blood pressure, keep it normal;
5. Learn how to effectively relieve stress with relaxation or yoga techniques.

Patients with ischemia of the heart must also have a good rest, you need to sleep at least 8 hours. You can not overeat, and the last meal of the day should be carried out no later than 3 hours before bedtime. Get outdoors more often and gradually increase the duration of your walks.

Folk methods for the prevention of coronary artery disease

In order to avoid the occurrence of cardiac ischemia in the future or to slow down its development, along with traditional treatment, it is extremely useful to follow folk old recipes.

Treatment of ischemia with wild rose and hawthorn

It is very useful to drink in the treatment of ischemia of the heart infusion of hawthorn and wild rose. You need to brew the fruits like tea, insisting for 2 hours, and drink half a glass 3-4 times a day.

Rosehip can also be used for baths. 500 g of wild rose should be poured with 3 liters of boiling water and boil the mixture over low heat for ten minutes. Then it is cooled and filtered, added to the bath. Keep the water temperature around 38 degrees, you will need to carry out at least 20 procedures to get a good result.

The benefits of garlic

1. Peel the average young garlic, crush it into gruel, put it in a jar;
2. Pour the garlic mass with a glass of sunflower oil, refrigerate;
3. Every other day, squeeze about one tablespoon of lemon juice into a glass, add a teaspoon of cooked garlic oil and swallow the mixture.

Do this daily 3 times half an hour before meals. After three months of the course, take a break, after which the treatment of ischemia with garlic can be resumed.

Folk recipes for the treatment of ischemia

Treatment of cardiac ischemia, along with drugs prescribed by a cardiologist, can also be carried out using traditional medicine. Below we present several effective recipes that often help to more successfully recover from coronary disease and eliminate the causes of its occurrence:

1. Fennel. 10 gr. fruit pour a glass of boiling water. Heat the mixture for a short time in a water bath, cool and strain. After that, the volume must be brought to 200 ml. Take a decoction should be up to four times daily for a tablespoon. Especially helpful in the treatment of coronary insufficiency.
2. Horseradish honey. Grate horseradish on a fine grater, mix a teaspoon of it with the same amount of honey. This should be done immediately before use, but it is advisable to take the remedy for treatment for a month. You can drink the mixture only with water.
3. Sushenitsa marsh. Pour it (10 g) with a glass of boiling water and for 15 minutes. put in a water bath. For ¾ hours, cool the mixture, strain, bring the volume to 200 ml. Drink should be half a glass after a meal. Effectively helps in the treatment of angina pectoris.
4. Hawthorn tea. Brew dried fruits in the same way as regular tea. The color is like not very strong black tea. It is used for ischemia of the heart and any heart disease, you can drink with sugar.
5. Hawthorn with motherwort. It was previously considered an indispensable tool for the treatment of cardiac ischemia. Mix hawthorn fruits with motherwort, 6 tablespoons each. Pour in 7 cups of boiling water, but do not boil the brew. Wrap the container with a blanket and leave for a day. Then strain the infusion, you can take it up to 3 times daily. Mix with rose hips (broth) if desired, but do not sweeten. Store in refrigerator.
6. Strawberry leaf. Pour 20 g of leaves with boiling water, boil a glass of the mixture for a quarter of an hour, after which it must be infused for two hours. Strain the broth and bring it to the original amount with boiled water. Take for ischemia a tablespoon up to four times a day at any time.

Nutrition for IHD

Taking pills alone for ischemia of the heart, prescribed by a doctor, is not enough to get the result of treatment. It is also important to reduce cholesterol and strengthen the heart to eat right. First of all, you need to limit the consumption of foods rich in saturated fats as much as possible. It is mainly food of animal origin - meat, eggs, milk, butter, sausages.

Cardiac ischemia is not a reason to completely abandon these products, but at the same time, milk should be consumed exclusively skimmed, and meat should be lean, without fat. The best option in this case is turkey, veal, chicken and rabbit meat. All visible fat from meat must be removed during cooking. And when baking in the oven, place the meat on a wire rack to remove excess fat. When making scrambled eggs and scrambled eggs, use no more than one egg per serving. To increase the volume of the dish, add only protein.

Fish, on the contrary, with ischemia of the heart, you should choose the fattest, for example, mackerel. Fish oil contains many important components for cholesterol metabolism. And there is also a lot of iodine in sea fish, which prevents the formation of sclerotic plaques. In excess, this component is also found in seaweed. The latter also dissolves blood clots that cause blood clots.

Unsaturated fats, on the contrary, are necessary for patients with ischemia of the heart. In the body, they contribute to the production of the so-called. "good" cholesterol. These components are found in vegetable oil, any - olive, sunflower, etc. Reduce the amount of cholesterol foods that are high in dietary fiber. These are vegetables, bran bread, nuts, beans.

Berries are also very useful for heart ischemia, because they contain salicylic acid, which prevents the formation of blood clots. You need to eat bananas, peaches, dried apricots and other foods rich in potassium. You should also refuse salty and too spicy foods, and also do not drink a lot of fluids. It is better to eat small meals up to five times a day. Limit yourself to vegetarian food a couple of times a week.

The value of physical activity in coronary artery disease

In the treatment of cardiac ischemia, physical training is of no small importance. If the disease is in the initial stage, the patient is shown swimming, cycling - not too intense loads of a cyclic nature. They should not be carried out only during periods of exacerbation.

If the patient has a severe form of cardiac ischemia, then complexes of special therapeutic exercises are used as a load. It is selected by the attending physician, taking into account the patient's condition. Classes should be conducted by an instructor in a hospital, clinic and under the supervision of a physician. After the course, the patient can independently perform the same exercises at home.