Coronary heart disease treatment drugs. Result of high blood pressure in relation to coronary artery disease
I’ll say right away about the abbreviation IBS used later in the text. This is a shortened name coronary disease hearts. This dangerous disease represents acute or chronic cardiac dysfunction. The disease occurs due to a violation of the patency of blood vessels, which should allow the flow of blood and oxygen directly to the heart muscle.
However, if blood clots (atherosclerotic plaques) form in the vascular cavity, they become narrowed, blocked, and blood flow is disrupted. This narrowing and blockage of the vessel cavity by a thrombus is called ischemia.
In addition to sclerotic plaques, vascular spasm can also disrupt blood flow. This happens with severe, sudden stress, pathological change psycho-emotional state sick.
Modern medicine has many methods of treating this pathology, which are widely used with varying degrees efficiency. Let's talk today about the signs of coronary artery disease, modern treatment, and briefly consider treatment methods:
Symptoms of ischemia
IHD usually develops in the second half of life, most often after 50 years. Symptoms usually appear after physical activity and appear as follows:
There are signs of angina pectoris (pain in the chest area).
- There is a feeling of insufficiency of inhaled air, the inhalation itself is difficult.
- Sudden cessation of blood circulation due to pathologically frequent contractions of the heart muscle (more than 300 contractions per minute), with all the ensuing consequences.
Even after familiarizing yourself with the symptoms of coronary artery disease, you need to know that some patients do not feel any signs of this dangerous disease at all, even if they have a heart attack.
Modern treatment coronary disease
IHD therapy is carried out in several areas:
Drug treatment: Special medications are used to reduce attacks of the disease, its intensity and frequency. Medicines are intended to strengthen the heart, increase patency coronary vessels. Drug therapy is usually used to treat ischemia on early stages when drugs are most effective.
Surgery : With the help of surgical intervention, ischemic heart disease is treated in acute cases, when it is necessary and most effective. Before the operation, the patient’s condition is stabilized, examined, tested, prepared for surgical intervention. The operation is stenting or coronary artery bypass grafting, which involves expanding the lumen of blood vessels, removing the obstruction and stimulating the necessary blood flow to the heart muscle.
Non-surgical treatment of the heart and blood vessels:
Unfortunately, drug therapy is not always effective, and coronary artery bypass grafting (surgical operation) cannot be performed for some reason. Therefore, patients should know that modern non-invasive treatment methods have been developed that help combat ischemia without undergoing major surgery. Here are some non-surgical treatment methods:
Shock wave therapy. This modern method of treating IHD involves the use of a shock wave generator, which is specially designed taking into account the clinical anatomical features chest. Shock wave therapy is carried out in several courses. As a result of treatment, angina pectoris decreases, the frequency and pain of attacks decreases, and the need for frequent medications is eliminated.
EECP (external counterpulsation). This modern method is intended for the treatment of coronary artery disease, angina pectoris, and heart failure. Often performed when drug therapy is insufficiently effective. EECP is recommended for patients with severe concomitant diseases, such as diabetes. Treatment can be carried out on an outpatient basis.
The result of treatment is a decrease in the class of angina pectoris, a decrease in the frequency and severity of attacks, and a decrease in the need for medications. After treatment there are virtually no side effects or complications.
Gravitational. This method involves the use of a physiotherapeutic factor of increased gravity. The treatment is indicated for therapeutic, orthopedic and surgical profiles; it is the latest medical technique. During treatment, there is increased muscle load on the lower extremities.
As a result, increased blood flow is achieved, collateral circulation is enhanced, the development of ischemia is stopped, and metabolism is improved. This method is very well tolerated by patients, is effective and improves the quality of drug treatment.
Stem cells. A new method of treating coronary artery disease is the use of the patient’s own stem cells. This treatment is prescribed after a thorough examination, which will confirm the effectiveness of cellular treatment in each specific case.
The need to use a particular treatment method is determined by the attending physician, taking into account the data of the examinations performed, the severity of the patient’s condition, his age and other indicators.
Remember that IHD is a very dangerous disease, the treatment of which does not require delay. Therefore, if symptoms are present, painful sensations in the chest, consult a cardiologist immediately. Be healthy!
Coronary heart disease (CHD) is one of the main causes of temporary and permanent disability in the developed countries of the world. In this regard, the problem of IHD occupies one of the leading places among the most important medical problems XXI century.
The fate of patients with coronary artery disease largely depends on the adequacy of the treatment outpatient treatment, quality and timeliness of diagnosis of those clinical forms of the disease that require providing the patient emergency care or urgent hospitalization.
Alexander Gorkov, head of the department of X-ray surgical methods of diagnosis and treatment of the District Cardiological Dispensary (Surgut, Khanty-Mansi Autonomous Okrug - Yugra), spoke about modern methods of treating coronary heart disease.
Q: Alexander Igorevich, what is IHD?
Coronary heart disease is characterized by an absolute or relative disruption of the blood supply to the myocardium due to damage to the coronary arteries of the heart. In other words, the myocardium needs more oxygen than is supplied by the blood. If IHD were manifested only by symptoms of ischemia, then it would be enough to constantly take nitroglycerin and not worry about the work of the heart. The term coronary heart disease includes a number of diseases (arterial hypertension, heart rhythm disturbances, heart failure, etc.) that are based on one cause - vascular atherosclerosis.
Q: Are heart pain and nitroglycerin the lot of older people?
Previously it was thought so, but now coronary heart disease does not bypass the younger generation either. Many factors of modern reality play a role in this development of IHD: ecology, hereditary predisposition, lifestyle associated with smoking, physical inactivity and a diet rich in fats.
Q: What effective methods of treating coronary heart disease have appeared in the arsenal of cardiologists over the past decades?
Modern development of technology also accompanies the improvement of treatment methods, but its main principle remains the same - restoration of blood flow through a narrowed or blocked coronary artery for normal nutrition of the myocardium. This can be achieved in two ways: medication and surgery.
Drug therapy with modern drugs with a proven level of effectiveness is today the basic basis for the treatment of chronic ischemic heart disease. Treatment is aimed at improving the patient’s quality of life, that is, reducing the severity of symptoms, preventing the development of forms of coronary artery disease such as myocardial infarction, unstable angina, and sudden cardiac death.
For this purpose, cardiologists have in their arsenal various drugs, which reduce the content of “bad” cholesterol in the blood, which is responsible for the formation of plaques on the walls of blood vessels. In addition, in the treatment of coronary heart disease, drugs are used that need to be taken once a day: these are antiplatelet agents (thin the blood), antiarrhythmics, antihypertensives and others. It should be noted that only a cardiologist can prescribe these medications based on the objective picture of the disease.
In more severe cases of coronary artery disease, surgical treatment methods are used. Endovascular surgery is considered the most effective method of treating coronary heart disease. This relatively young area of medicine has already gained a strong position in the treatment of coronary artery disease. All interventions are performed without incisions, through a puncture under X-ray observation. These features are important for those patients who are contraindicated (due to concomitant diseases or general weakening of the body) traditional surgical intervention.
Among the methods of endovascular surgery for coronary artery disease, balloon angioplasty and stenting are used, which make it possible to restore patency in arteries affected by ischemia. The essence of the method is that a special balloon is inserted into the vessel, then it is inflated and “pushes” atherosclerotic plaques or blood clots to the sides. After this, a cylindrical stent (a wire structure made of a special alloy) is installed in the artery, which is able to maintain the shape given to the vessel.
A generally accepted and effective method of surgical blood flow in a narrowed or blocked artery is coronary artery bypass surgery, when the artery blocked by a plaque or thrombus is replaced by an “artificial vessel” that takes over the blood flow. These operations are almost always performed on a non-functioning heart under conditions of artificial circulation, for which there are clear indications.
However, the positive effect after surgical and endovascular treatment is stable and long-lasting.
Q: Alexander Igorevich, what is the reason for choosing the method used?
The state of human health, the degree of damage to the coronary arteries by atherosclerotic plaques or blood clots, and one of the important indicators is time! Within efficient work in the Khanty-Mansi Autonomous Okrug - Ugra of the "Ugra-Kor" project, patients from all over the district in the first hours from the beginning pain syndrome end up in one of three Interventional Cardiology Centers, including the District Cardiology Clinic, and doctors manage to provide assistance using low-traumatic surgical methods. In 2012, the cardiac center performed about 1,100 angioplasty operations, of which about 300 were performed on patients with acute coronary syndrome as part of the Ugra-Kor project.
Q: Alexander Igorevich, tell us how the life of a person diagnosed with coronary heart disease should change?
Treatment of coronary artery disease involves joint work between the cardiologist and the patient in several areas. First of all, care must be taken to change lifestyle and address the risk factors for coronary heart disease. This includes quitting smoking and correcting cholesterol levels through diet or medication. Very important point Non-drug treatment of coronary artery disease is the fight against a sedentary lifestyle by increasing the patient’s physical activity. And, of course, preliminary treatment of concomitant diseases, if the development of IHD occurs against their background.
Modern methods of treating coronary heart disease are quite effective in helping people live a better and longer life. But health is the daily result of a person’s work on himself. Focus your energy on conservation own health and take care of your heart health!
Treatment of coronary heart disease primarily depends on the clinical form. For example, although some general principles of treatment are used for angina and myocardial infarction, treatment tactics, selection of activity regimens and specific medications may differ radically. However, there are some general directions, important for all forms of IHD.
1. Limiting physical activity. During physical activity, the load on the myocardium increases, and as a result, the myocardium’s need for oxygen and nutrients. If the blood supply to the myocardium is disrupted, this need is unsatisfied, which actually leads to manifestations of coronary artery disease. Therefore, the most important component of the treatment of any form of coronary artery disease is limiting physical activity and gradually increasing it during rehabilitation.
2. Diet. In case of coronary artery disease, in order to reduce the load on the myocardium, the intake of water and sodium chloride (table salt) is limited in the diet. In addition, given the importance of atherosclerosis in the pathogenesis of coronary artery disease, much attention is paid to limiting foods that contribute to the progression of atherosclerosis. An important component of the treatment of coronary artery disease is the fight against obesity as a risk factor.
The following food groups should be limited, or if possible avoided.
Animal fats (lard, butter, fatty meats)
Fried and smoked food.
Products containing large amounts of salt (salted cabbage, salty fish and so on)
Limit intake of high-calorie foods, especially quickly absorbed carbohydrates. (chocolate, candy, cakes, pastry).
To correct body weight, it is especially important to monitor the ratio of energy coming from the food eaten and energy expenditure as a result of the body’s activities. For sustainable weight loss, the deficit must be at least 300 kilocalories daily. On average, a person not engaged in physical work spends 2000-2500 kilocalories per day.
3. Pharmacotherapy for ischemic heart disease. There are a number of groups of drugs that may be indicated for use in one form or another of coronary artery disease. In the USA there is a formula for the treatment of coronary artery disease: “A-B-C”. It involves the use of a triad of drugs, namely antiplatelet agents, β-blockers and hypocholesterolemic drugs.
Also, if there are accompanying hypertension, it is necessary to ensure achievement of target levels blood pressure.
Antiplatelet agents (A). Antiplatelet agents prevent the aggregation of platelets and red blood cells, reduce their ability to glue and adhere to the vascular endothelium. Antiplatelet agents facilitate the deformation of red blood cells when passing through capillaries and improve blood fluidity.
Aspirin - taken once a day in a dose of 100 mg; if myocardial infarction is suspected, a single dose can reach 500 mg.
Clopidogrel - taken once a day, 1 tablet of 75 mg. It is required to take it for 9 months after endovascular interventions and CABG.
Adrenergic blockers (B). Due to their action on β-arenoceptors, adrenergic blockers reduce the heart rate and, as a consequence, myocardial oxygen consumption. Independent randomized studies confirm an increase in life expectancy when taking β-blockers and a decrease in the incidence of cardiovascular events, including recurrent ones. Currently, it is not advisable to use the drug atenolol, since according to randomized studies it does not improve the prognosis. β-blockers are contraindicated in case of concomitant pulmonary pathology, bronchial asthma, COPD. Below are the most popular β-blockers with proven properties of improving the prognosis for coronary artery disease.
Metoprolol (Betalok Zok, Betalok, Egilok, Metocard, Vasocardin);
Bisoprolol (Concor, Coronal, Bisogamma, Biprol);
Carvedilol (Dilatrend, Talliton, Coriol).
Statins and Fibrates (C). Cholesterol-lowering drugs are used to reduce the rate of development of existing atherosclerotic plaques and prevent the formation of new ones. Proven positive influence on life expectancy, these drugs also reduce the frequency and severity of cardiovascular events. The target cholesterol level in patients with coronary artery disease should be lower than in persons without coronary artery disease and equal to 4.5 mmol/l. Target LDL level in patients with coronary artery disease - 2.5 mmol/l.
Lovastatin;
Simvastatin;
Atorvastatin;
Rosuvastatin (the only drug that significantly reduces the size of atherosclerotic plaque);
Fibrates. They belong to a class of drugs that increase the antiatherogenic fraction of HDL, with a decrease in which the mortality rate from coronary artery disease increases. Used to treat dyslipidemia IIa, IIb, III, IV, V. They differ from statins in that they mainly reduce triglycerides (VLDL) and can increase the HDL fraction. Statins primarily reduce LDL and do not have a significant effect on VLDL and HDL. Therefore, a combination of statins and fibrates is required to most effectively treat macrovascular complications. With the use of fenofibrate, mortality from coronary artery disease is reduced by 25%. Of the fibrates, only fenofibrate is safely combined with any class of statins (FDA).
Fenofibrate
Other classes: omega-3 polyunsaturated fatty acid(Omakor). In case of ischemic heart disease, they are used to restore the phospholipid layer of the cardiomyocyte membrane. By restoring the structure of the cardiomyocyte membrane, Omacor restores the basic (vital) functions of cardiac cells - conductivity and contractility, which were impaired as a result of myocardial ischemia.
Nitrates. There are nitrates for injection.
Drugs in this group are derivatives of glycerol, triglycerides, diglycerides and monoglycerides. The mechanism of action is the influence of the nitro group (NO) on the contractile activity of vascular smooth muscles. Nitrates predominantly act on the venous wall, reducing the preload on the myocardium (by dilating the vessels of the venous bed and deposition of blood). A side effect of nitrates is a decrease in blood pressure and headaches. Nitrates are not recommended for use if blood pressure is below 100/60 mmHg. Art. In addition, it is now reliably known that taking nitrates does not improve the prognosis of patients with coronary artery disease, that is, it does not lead to an increase in survival, and are currently used as a drug to relieve the symptoms of angina pectoris. Intravenous drip administration of nitroglycerin can effectively combat the symptoms of angina pectoris, mainly against the background of high blood pressure numbers.
Nitrates exist in both injectable and tablet forms.
Nitroglycerine;
Isosorbide mononitrate.
Anticoagulants. Anticoagulants inhibit the appearance of fibrin filaments, they prevent the formation of blood clots, help stop the growth of existing blood clots, and enhance the effect of endogenous enzymes that destroy fibrin on blood clots.
Heparin (the mechanism of action is due to its ability to specifically bind to antithrombin III, which sharply increases the inhibitory effect of the latter on thrombin. As a result, the blood clots more slowly).
Heparin is injected under the skin of the abdomen or using an infusion pump intravenously. Myocardial infarction is an indication for heparin prophylaxis of blood clots; heparin is prescribed at a dose of 12,500 IU, injected under the skin of the abdomen daily for 5-7 days. In the ICU, heparin is administered to the patient using an infusion pump. The instrumental criterion for prescribing heparin is the presence of depression of the S-T segment on the ECG, which indicates an acute process. This sign important in terms of differential diagnosis, for example, in cases where the patient has ECG signs previous heart attacks.
Diuretics. Diuretics are designed to reduce the load on the myocardium by reducing the volume of circulating blood due to the accelerated removal of fluid from the body.
Loopbacks. The drug "Furosemide" in tablet form.
Loop diuretics reduce the reabsorption of Na+, K+, Cl- in the thick ascending limb of the loop of Henle, thereby reducing the reabsorption (reabsorption) of water. They have quite pronounced quick action, usually used as drugs emergency assistance(for forced diuresis).
The most common drug in this group is furosemide (Lasix). Available in injection and tablet forms.
Thiazide. Thiazide diuretics are Ca2+-sparing diuretics. By reducing the reabsorption of Na+ and Cl- in the thick segment of the ascending limb of the loop of Henle and the initial part of the distal tubule of the nephron, thiazide drugs reduce urine reabsorption. With systematic use of drugs in this group, the risk of cardiovascular complications in the presence of concomitant hypertension is reduced.
Hypothiazide;
Indapamide.
Angiotensin-converting enzyme inhibitors. By acting on the angiotensin-converting enzyme (ACE), this group of drugs blocks the formation of angiotensin II from angiotensin I, thus preventing the effects of angiotensin II, that is, leveling vasospasm. This ensures that target blood pressure levels are maintained. Drugs in this group have nephro- and cardioprotective effects.
Enalapril;
Lisinopril;
Captopril.
Antiarrhythmic drugs. The drug "Amiodarone" is available in tablet form.
Amiodarone refers to III group antiarrhythmic drugs, has a complex antiarrhythmic effect. This drug acts on the Na+ and K+ channels of cardiomyocytes, and also blocks β- and β-adrenergic receptors. Thus, amiodarone has antianginal and antiarrhythmic effects. According to randomized clinical trials, the drug increases the life expectancy of patients who regularly take it. When taking tablet forms of amiodarone clinical effect observed after approximately 2-3 days. The maximum effect is achieved after 8-12 weeks. This is due to the long half-life of the drug (2-3 months). Due to this this drug It is used for the prevention of arrhythmias and is not an emergency treatment.
Taking into account these properties of the drug, the following scheme of its use is recommended. During the saturation period (the first 7-15 days), amiodarone is prescribed at daily dose 10 mg/kg of the patient’s weight in 2-3 doses. With the onset of a persistent antiarrhythmic effect, confirmed by the results of daily ECG monitoring, the dose is gradually reduced by 200 mg every 5 days until a maintenance dose of 200 mg per day is reached.
Other groups of drugs.
Ethylmethylhydroxypyridine
The drug "Mexidol" in tablet form. Metabolic cytoprotector, antioxidant-antihypoxant, which has a complex effect on key links in pathogenesis cardiovascular diseases: anti-atherosclerotic, anti-ischemic, membrane-protective. Theoretically, ethylmethylhydroxypyridine succinate has a significant positive effect, but currently, data on its clinical effectiveness There are no independent randomized placebo-controlled studies based on them.
Mexico;
Coronator;
Trimetazidine.
4. Use of antibiotics for ischemic heart disease. There are results of clinical observations of the comparative effectiveness of two different courses of antibiotics and placebo in patients admitted to the hospital or with acute heart attack myocardium, or with unstable angina. Studies have shown the effectiveness of a number of antibiotics in the treatment of coronary artery disease. The effectiveness of this type of therapy is not pathogenetically substantiated, and this technique is not included in the standards of treatment for coronary artery disease.
5. Endovascular coronary angioplasty. The use of endovascular (transluminal, transluminal) interventions (coronary angioplasty) for various forms of coronary artery disease is developing. Such interventions include balloon angioplasty and stenting under the guidance of coronary angiography. In this case, the instruments are introduced through one of the large arteries(in most cases the femoral artery is used), and the procedure is performed under fluoroscopic guidance. In many cases, such interventions help prevent the development or progression of myocardial infarction and avoid open surgery.
This area of treatment of coronary artery disease is dealt with in a separate field of cardiology - interventional cardiology.
6. Surgical treatment.
Aorto-coronary bypass surgery is performed.
Under certain parameters of coronary heart disease, indications arise for coronary bypass surgery - an operation in which the blood supply to the myocardium is improved by connecting the coronary vessels below the site of their lesion with external vessels. The best known is coronary artery bypass grafting (CABG), in which the aorta is connected to segments of the coronary arteries. For this purpose, autografts (usually the great saphenous vein) are often used as shunts.
It is also possible to use balloon dilatation of blood vessels. In this operation, the manipulator is inserted into the coronary vessels through puncture of the artery (usually femoral or radial), and using a balloon filled contrast agent The lumen of the vessel is widened; the operation is essentially a bougienage of the coronary vessels. Currently, “pure” balloon angioplasty without subsequent stent implantation is practically not used, due to its low effectiveness in the long term.
7. Other non-drug treatments
Hirudotherapy. Hirudotherapy is a treatment method based on the use of the antiplatelet properties of leech saliva. This method is an alternative and has not been clinically tested to meet the requirements evidence-based medicine. Currently used relatively rarely in Russia, it is not included in the standards of provision medical care for ischemic heart disease, it is used, as a rule, at the request of patients. Potential beneficial effects of this method include the prevention of blood clots. It is worth noting that when treated according to approved standards, this task is performed using heparin prophylaxis.
Shock wave therapy method. Exposure to low power shock waves leads to myocardial revascularization.
An extracorporeal source of focused acoustic wave allows remote influence on the heart, causing “therapeutic angiogenesis” (vascular formation) in the zone of myocardial ischemia. Exposure to UVT has a double effect - short-term and long-term. First, the vessels dilate and blood flow improves. But the most important thing begins later - new vessels appear in the affected area, which provide long-term improvement.
Low-intensity shock waves cause shear stress in the vascular wall. This stimulates the release of factors vascular growth, starting the process of growth of new vessels that nourish the heart, improving myocardial microcirculation and reducing angina. The results of such treatment are theoretically a decrease in the functional class of angina, an increase in exercise tolerance, a decrease in the frequency of attacks and the need for medications.
However, it should be noted that at present there have been no adequate independent multicenter randomized studies evaluating the effectiveness of this technique. Studies cited as evidence of the effectiveness of this technique are usually carried out by the manufacturing companies themselves. Or do not meet the criteria of evidence-based medicine.
This method is not widely used in Russia due to questionable effectiveness, high cost of equipment, and lack of appropriate specialists. In 2008, this method was not included in the standard of medical care for coronary artery disease, and these manipulations were carried out on a contractual basis. on a commercial basis, or in some cases under voluntary health insurance contracts.
Use of stem cells. When using stem cells, those performing the procedure expect that the pluripotent stem cells introduced into the patient’s body will differentiate into the missing cells of the myocardium or vascular adventitia. It should be noted that stem cells actually have this ability, but at present the level of modern technology does not allow us to differentiate a pluripotent cell into the tissue we need. The cell itself makes the choice of differentiation path - and often not the one needed for the treatment of IHD.
This treatment method is promising, but has not yet been clinically tested and does not meet the criteria of evidence-based medicine. It takes years of scientific research to achieve the effect that patients expect from the introduction of pluripotent stem cells.
Currently, this treatment method is not used in official medicine and is not included in the standard of care for IHD.
Quantum therapy for ischemic heart disease. It is a therapy using laser radiation. The effectiveness of this method has not been proven, and no independent clinical study has been conducted.
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 throughout the world. In Russia, the prevalence of cardiovascular diseases and coronary heart disease is growing, and in terms of mortality from them, our country is one of the first in the world, which necessitates the use by doctors of modern and effective methods their treatment and prevention. Among the population of Russia, there remains a high prevalence of the main risk factors for the development of coronary artery disease, of which highest value have smoking, arterial hypertension, hypercholesterolemia.
Atherosclerosis is main reason development of ischemic heart disease. It proceeds covertly for a 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, and 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, factors such as endothelial dysfunction, regional spasms, impaired microcirculation, as well as the presence of a primary inflammatory process in the vascular wall as a possible factor in the formation of thrombosis take part in its development. An imbalance of vasodilating and vasoconstrictor stimuli can also significantly change the state of the tone of the coronary arteries, creating 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 suffered a myocardial infarction, constitute the largest group of patients with coronary artery disease. This explains the interest of practicing physicians in the issues of proper management of patients with angina pectoris and the choice of optimal treatment methods.
Clinical forms of IHD. IHD manifests itself in many clinical forms: chronic stable angina, unstable (progressive) angina, asymptomatic IHD, 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 development 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. Antianginal treatment is considered successful in the case of complete or almost complete elimination of angina attacks and the patient’s return to normal activity (angina pectoris is not higher than functional class I, when painful attacks occur only under significant loads) and with minimal side effects of therapy.
In the treatment of chronic ischemic heart 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, if there is a large selection of modern antianginal and anti-ischemic drugs, outdated and insufficiently effective ones should be excluded. A frank conversation with the patient, an explanation of the cause of the disease and its complications, and the need for additional non-invasive and invasive research methods helps to choose the right treatment method.
According to the results of the ATP-survey (Angina Treatment Patterns), in Russia, when choosing antianginal drugs with a hemodynamic mechanism of action in monotherapy, preference is given to nitrates (11.9%), then b-blockers (7.8%) and calcium antagonists (2 .7%).
β-blockers are the first choice drugs for the treatment of patients with angina pectoris, especially in patients who have had a myocardial infarction, as they lead to a reduction in mortality and the incidence of recurrent infarction. 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 the myocardial oxygen demand (due to a decrease in heart rate, lowering blood pressure and myocardial contractility), increasing oxygen delivery to the myocardium (due to increased collateral blood flow, its redistribution in favor of the ischemic layers of the myocardium - subendocardium ), antiarrhythmic and antiaggregation effects, reducing calcium accumulation in ischemic cardiomyocytes.
Indications for the use of β-blockers are the presence of angina, angina with concomitant arterial hypertension, concomitant heart failure, “silent” myocardial ischemia, myocardial ischemia with concomitant rhythm disturbances. 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 the long-term prognosis of a patient with coronary artery disease.
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 a day morning hours. At pronounced violation renal function, the daily dose should be reduced.
Another cardioselective β-blocker is metoprolol (Betaloc). Its daily dose is on average 100-300 mg, the drug is prescribed in 2 doses, since the β-blocking effect can be observed for up to 12 hours. Currently, long-acting metoprolol preparations have become widespread - betaloc ZOK, metocard, the duration of the effect of which reaches 24 hours.
Bisoprolol (Concor), in comparison with atenolol and metoprolol, has 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 having 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-adrenergic blocking and vasodilating activity, which is mainly associated with 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 erythrocytes and platelets. In patients with impaired left ventricular (LV) function or circulatory failure, carvedilol has a beneficial effect on hemodynamic parameters (reduces pre- and afterload), increases ejection fraction and reduces LV size. Thus, the administration of carvedilol is indicated primarily for patients with coronary artery disease who have suffered a 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 (average daily dose 20.5 mg) and atenolol (average daily dose 25.9 mg), both drugs, administered twice daily, were shown to be equally effective in the treatment of patients with stable angina pectoris. One of the guidelines for the adequacy of the dose of beta-blockers used is a decrease 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: it reduces blood pressure, pre- and afterload, increases cardiac output, and increases peripheral blood flow. Nebivolol is a b-blocker with unique properties, which lie in the ability of the drug to participate in the process of synthesis of 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 attacks of angina pectoris.
Celiprolol (200-600 mg/day) - a third-generation β-blocker - differs from other β-blockers in its high selectivity, moderate stimulation of β 2 -adrenergic receptors, direct vasodilating effect on blood vessels, modulation of the release of nitric oxide from endothelial cells, and the absence of adverse metabolic effects . The drug is recommended for patients with coronary artery disease with chronic obstructive pulmonary diseases, dyslipidemia, diabetes mellitus, and peripheral vascular diseases 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 angina pectoris.
β-blockers should be given preference when prescribed to patients with coronary artery disease if there is a clear connection between physical activity and the development of an angina attack, with concomitant arterial hypertension; the presence of rhythm disturbances (supraventricular or ventricular arrhythmia), previous myocardial infarction, severe anxiety. Most of the adverse effects of β-blockers are due to blockade of β 2 receptors. The need to monitor the prescription of β-blockers and the side effects encountered (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. The main medical errors when prescribing β-blockers are the use of small doses of drugs, their administration less frequently than necessary, and the discontinuation of drugs when a heart rate at rest is less than 60 beats/min. One should also keep in mind the possibility of developing withdrawal syndrome, and therefore β-blockers must be discontinued gradually.
Calcium channel blockers (calcium antagonists). The main point of application of drugs of this group at the cellular level are slow calcium channels, through which calcium ions pass into smooth muscle cells blood vessels and hearts. In the presence of calcium ions, actin and myosin interact, ensuring contractility of the myocardium and smooth muscle cells. In addition, calcium channels are involved in the generation of pacemaker activity of sinus node cells and conduction of impulses through the atrioventricular node.
It has been established that the vasodilating effect caused by calcium antagonists occurs not only through a direct effect on the smooth muscles of the vascular wall, but also indirectly, through 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 of angina from dihydropyridine derivatives, it is recommended to use only prolonged dosage forms or long-acting generations of calcium antagonists. Calcium channel blockers are powerful vasodilators; they reduce myocardial oxygen demand and dilate coronary arteries. The drugs can be used for vasospastic angina and concomitant obstructive pulmonary diseases. Additional indications for the prescription of calcium antagonists are Raynaud's syndrome, as well as (for phenylalkylamines - verapamil and benzodiazepines - diltiazem) atrial fibrillation, supraventricular tachycardia, hypertrophic cardiomyopathy. Among the calcium antagonists used in the treatment of coronary artery disease: nifedipine 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); immediate-release diltiazem (30-60 mg 4 times a day) or long-acting (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 considered 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 for unstable angina, acute myocardial infarction and, apparently, with long-term use in patients with stable angina pectoris . In this regard, it is currently recommended to use retard and prolonged forms of dihydropyridines. They have no fundamental differences in the nature of pharmacodynamic action with short-acting drugs. Due to gradual absorption, they are devoid of a number of side effects associated with sympathetic activation, so characteristic of short-acting dihydropyridines.
In recent years, evidence has emerged indicating the possibility of slowing down damage to the vascular wall with the help of calcium antagonists, especially in the early stages of the development of atherosclerosis.
Amlodipine (Norvasc, Amlovas, Nordipine) is a third generation calcium antagonist from the group of dihydropyridines. Amlodipine dilates peripheral blood vessels and reduces cardiac afterload. Due to the fact that the drug does not cause reflex tachycardia (since the sympathoadrenal system is not activated), energy consumption and myocardial oxygen demand are reduced. The drug dilates the coronary arteries and increases the supply of oxygen to the myocardium. Antianginal effect (reducing the frequency and duration of angina attacks, daily requirement for nitroglycerin), increasing tolerance to physical activity, improving systolic and diastolic heart function in the absence of a depressing effect on the sinus and atrioventricular node and other elements of the conduction system of the heart put the drug in one of the first places in the treatment of angina pectoris.
Lacidipine, a third-generation drug from the class of calcium antagonists, has high lipophilicity, interaction with the cell membrane, and independence of tissue effects from its concentration. These factors are leading in the mechanism of antiatherosclerotic action. Lacidipine has a positive effect on the endothelium, inhibits the formation of adhesion molecules, proliferation of smooth muscle cells and platelet aggregation. In addition, the drug is able to inhibit the peroxidation of low-density lipoproteins, i.e., it can affect one of the early stages of plaque formation.
The European Lacidipine Study on Atherosclerosis (ELSA) compared the intima-media thickness of the carotid artery 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 intima-media thickness, both at the level of the bifurcation and the common carotid artery, compared to atenolol. 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 antiatherogenic effect (stabilization 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 with arterial damage different localization. Currently, calcium antagonists are considered second-line drugs in patients with angina pectoris, 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 who have had 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, and having had a myocardial infarction without a Q wave.
Thus, the undoubted advantage of calcium antagonists is a wide range of pharmacological effects aimed at eliminating the manifestations of coronary insufficiency: antianginal, hypotensive, antiarrhythmic. Therapy with these drugs also has a beneficial effect on 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 and rest in patients with coronary artery disease (also in in order to prevent them), attacks of vasospastic angina, attacks of angina, accompanied by manifestations of left ventricular failure.
Sublingual nitroglycerin (0.3-0.6 mg) or nitroglycerin aerosol (Nitromint 0.4 mg) is intended for the relief of acute attacks of angina 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 attack of angina, chewing or dissolving the tablets when taking them under the tongue.
Organic nitrates (preparations 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 try to prescribe them before physical activity that causes angina. Of the drugs with proven effectiveness, the most studied are cardiquet (20, 40, 60 and 120 mg/day), nitrosorbide (40-80 mg/day), olicard retard (40 mg/day), mono poppy (20-80 mg/day ), mono mac depot (50 and 100 mg/day), efox long (50 mg/day), mono cinque retard (50 mg/day). For patients with stable angina pectoris class I-II, intermittent administration of nitrates is possible before situations that can cause an attack of angina. For patients with more severe angina pectoris class III-IV, nitrates should be prescribed regularly; In such patients, one should strive to maintain the effect throughout the day. For class IV angina (when angina attacks can also occur at night), nitrates should be prescribed in such a way as to ensure the effect throughout the day.
Nitrate-like drugs include molsidomine (Corvaton, Sidnopharm, Dilasidom), a drug different from nitrates in 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 anti-aggregation properties. Comparable doses of isosorbide dinitrate and corvatone are 10 mg and 2 mg, respectively. The effect of Corvaton appears after 15-20 minutes, the duration of action is from 1 to 6 hours (on 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 disadvantage of nitrates is the development of tolerance to them, especially with long-term use, and side effects that make their use difficult ( 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 dosing them and the development of tolerance to them, have not found widespread use. It is also unknown whether nitrates improve the prognosis of a patient with stable angina with long-term use, which makes the advisability of their use in the absence of angina pectoris (myocardial ischemia) questionable.
When prescribing drugs with a hemodynamic mechanism of action in elderly patients, the following rules should be observed: start treatment with lower doses, carefully monitor unwanted effects, and always consider changing the drug if it is poorly tolerated and insufficiently effective.
Combination therapy. Combination therapy with antianginal drugs in patients with stable angina of class III-IV is carried out for the following indications: impossibility of selecting effective monotherapy; the need to enhance the effect of monotherapy (for example, during periods of increased physical activity of the patient); correction of unfavorable hemodynamic changes (for example, tachycardia caused by nitrates or calcium antagonists from the dihydropyridine group); when angina is combined with arterial hypertension or heart rhythm disturbances that are not compensated for in cases of monotherapy; in case of patient intolerance to generally accepted doses of drugs during monotherapy, small doses of drugs can be combined to achieve the desired effect.
The synergism of the mechanisms of action of various 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 drugs (β-blockers, nitrates, calcium antagonists). In the absence of effect from monotherapy, combination therapy is often prescribed (nitrates and β-blockers; β-blockers and calcium antagonists, etc.).
The results of the ATP-survey study (review of the treatment of stable angina) showed that in Russia 76% of patients receive combination therapy with hemodynamic 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. The guidelines of the European Society of Cardiology (1997) indicate that if one antianginal drug is ineffective, it is better to first evaluate the effect of another, and only then use a combination. The results of pharmacological controlled studies do not confirm that combination therapy with a beta-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 at an optimal dose. We must not forget that the use of multiple drugs significantly increases the risk of adverse events associated with effects on hemodynamics.
The modern approach to combination therapy of patients with stable angina pectoris implies the advantage of combining antianginal drugs with multidirectional effects: hemodynamic and cytoprotective.
The main disadvantages of domestic pharmacotherapy for stable angina include the often erroneous, modern ideas, the choice of a group of antianginal drugs (as a rule, nitrates are prescribed (in 80%)), the frequent use of clinically insignificant dosages and the unreasonable prescription of combination therapy with a large number of antianginal drugs.
Metabolic agents. Trimetazidine (preductal) causes inhibition of fatty acid oxidation (by blocking the enzyme 3-ketoacyl-coenzyme A-thiolase) and stimulates the oxidation of pyruvate, 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 to cell membranes. A single dose of trimetazidine is not able to relieve or prevent an attack of angina. Its effects are observed mainly during combination therapy with other antianginal drugs or during a course of treatment. Preductal is effective and well tolerated, especially in groups at high risk of developing 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 basic hemodynamic antianginal drugs.
In Russia, a multicenter, single-blind, randomized, placebo-controlled, parallel-group study, TAST (Trimetazidin in patients with Angina in Combination Therapy), was conducted, which included 177 patients suffering from class II-III angina, partially relieved by nitrates and β-blockers, to evaluate the effectiveness of the preductal in combination therapy with nitrates or β-blockers. Evaluation of the effectiveness of treatment was carried out according to the following criteria: time until the onset of ST segment depression by 1 mm during stress tests, time of onset of angina pectoris, increase in the duration of the stress test. It was found that the 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 use .
Drugs with antianginal properties include amiodarone and other “metabolic” drugs (ranolazine, L-arginine), as well as ACE inhibitors, selective heart rate inhibitors (ivabradine, procolaran). They are used mainly as an adjuvant therapy, prescribed in addition to the main antianginal drugs.
The problem of drug treatment of patients with coronary artery disease is the patients’ insufficient adherence to the chosen therapy and their insufficient willingness to consistently change their lifestyle. During 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. When trying to influence the prognosis of a patient’s life with the help of drug therapy, the doctor must be sure that the medications he prescribes are actually taken by the patient, and in appropriate doses and according to the recommended treatment regimen.
Surgery. If drug therapy is ineffective, surgical treatment methods are used (myocardial revascularization procedures), which include: percutaneous transluminal coronary angioplasty, implantation of coronary stents, coronary artery bypass surgery. In patients with coronary artery disease, it is important to determine individual risk based on clinical and instrumental indicators, which depends on the corresponding clinical stage illness and treatment. Thus, the maximum effectiveness of coronary bypass surgery was observed in patients with the highest preoperative risk of developing cardiovascular complications (with severe angina and ischemia, extensive lesions of the coronary arteries, impaired LV function). With a low risk of developing complications of coronary artery disease (damage to one artery, absence or mild ischemia, normal function LV) surgical revascularization is usually not indicated until the failure of medical therapy or coronary angioplasty has been established. When deciding whether to use coronary angioplasty or coronary bypass surgery to treat patients with damage to multiple coronary arteries, the choice of method depends on the anatomical features of the coronary bed, LV function, the need to achieve complete myocardial revascularization and patient preferences.
Thus, with the methods of combating cardiovascular diseases that exist today (table), it is important for the doctor to be aware latest achievements medicine and make the right choice of treatment method.
For questions about literature, please contact the editor.
D. M. Aronov, Doctor of Medical Sciences, Professor V. P. Lupanov, Doctor of Medical Sciences, State Scientific Research Center for Preventive Medicine of the Ministry of Health of the Russian Federation, Institute of Clinical Cardiology named after. A. L. Myasnikov Russian Cardiological Research and Production Complex of the Ministry of Health of the Russian Federation, Moscow
Send your good work in the knowledge base is simple. Use the form below
Students, graduate students, young scientists who use the knowledge base in their studies and work will be very grateful to you.
Posted onhttp:// www. allbest. ru/ 9
INconducting
The heart is one of the main human organs. This is our engine, which works without rest, and if earlier, failures in its operation were observed in older people, now Lately Heart disease has become much younger and is at the top of the list of life-threatening diseases.
Relevance.Despite modern advances in medicine, the last decade has been characterized by a steady increase in cardiovascular diseases in the population. Atherosclerosis, coronary heart disease, hypertension and their complications have taken first place among the causes of morbidity, disability, disability and mortality in economically developed countries. In Russia, the annual mortality rate from cardiovascular causes exceeds one million people. Myocardial infarction develops in 0.9-1.4% of men aged 40-59 years, in men of the older age group - 2.1% per year. There has been a steady increase in incidence among young and middle-aged people. Despite the decrease in hospital mortality, the overall mortality from this disease remains high, reaching 40-60%. It should be noted that most of deaths occur in the prehospital stage.
Numerous epidemiological studies revealed a significant prevalence of arterial hypertension among the adult population. In European Union countries, the number of patients with high blood pressure reaches 20-30%, in Russia - 30-40%. Arterial hypertension is one of the main risk factors for the formation of coronary heart disease, cerebral stroke, and heart failure. These circumstances determine the great importance of introducing new advances in cardiology into practical healthcare.
Targetwork- study the basic modern principles of treatment of coronary heart disease.
1. IshamAndcheskayamoreeknowWitheheart
(IHD; lat. morbus ischaemicus cordis from ancient Greek ?uchch - “delay, restrain” and b?mb - “blood”) is a pathological condition characterized by an absolute or relative disruption of the blood supply to the myocardium due to damage to the coronary arteries.
Coronary heart disease is a myocardial lesion caused by a disorder of coronary circulation, resulting from an imbalance between coronary blood flow and the metabolic needs of the heart muscle. In other words, the myocardium needs more oxygen than is supplied by the blood. IHD can occur acutely (in the form of myocardial infarction), as well as chronically (recurrent attacks of angina).
IHD is a very common disease, one of the main causes of mortality, as well as temporary and permanent disability in the developed countries of the world. In this regard, the problem of IHD occupies one of the leading places among the most important medical problems of the 21st century.
In the 80s There was a tendency towards a decrease in mortality from IHD, but nevertheless, in developed European countries it accounted for about half of the total mortality of the population, while maintaining a significant uneven distribution among groups of people of different sexes and ages. In the USA in the 80s. The mortality rate for men aged 35-44 was about 60 per 100,000 population, with the ratio of men to women dying at this age being approximately 5:1. By the age of 65-74 years, the overall mortality from ischemic heart disease in both sexes reached more than 1,600 per 100,000 population, and the ratio between deceased men and women in this age group decreased to 2:1.
The fate of patients with ischemic heart disease, components a significant part the contingent observed by doctors largely depends on the adequacy of the outpatient treatment provided, on the quality and timeliness of diagnosis of those clinical forms of the disease that require emergency care or urgent hospitalization for the patient.
According to statistics, in Europe, IHD and cerebral stroke account for 90% of all diseases of the cardiovascular system, which characterizes IHD as one of the most common diseases.
1.1 EtiologyAndpathogenesis
A number of factors contribute to the occurrence of CAD. Among them, hypertension should be placed in first place, which is detected in 70% of patients with coronary artery disease. Hypertension contributes to a more rapid development of atherosclerosis and spasm of the coronary arteries of the heart. Diabetes mellitus, which contributes to the development of atherosclerosis due to impaired protein and lipid metabolism, is also a predisposing factor for the occurrence of coronary artery disease. When smoking, spasm of the coronary vessels develops, and blood clotting also increases, which contributes to the occurrence of thrombosis of altered coronary vessels. Genetic factors are of a certain importance. It has been established that if parents suffer from coronary artery disease, then in their children it occurs 4 times more often than in persons whose parents are healthy. Hypercholesterolemia significantly increases the likelihood of coronary artery disease, since it is one of the important factors contributing to the development of atherosclerosis in general and coronary vessels in particular. In obesity, coronary artery disease occurs several times more often than in people with normal body weight. In obese patients, the amount of cholesterol in the blood is increased; in addition, these patients lead a sedentary lifestyle, which also contributes to the development of atherosclerosis and coronary artery disease.
IHD is one of the most common diseases in industrialized countries. Over the past 30 years, the incidence of coronary artery disease has doubled, which is associated with mental stress. In men, IHD appears approximately 10 years earlier than in women. People who work physically get sick less often than people who work mentally.
1.2 Pathologicalanatomy
Pathological changes depend on the degree of damage to the coronary vessels by atherosclerosis. With angina pectoris, when there is no myocardial infarction, only small foci of cardiosclerosis are noted. Defeat is necessary at least 50% of the lumen area of one of the coronary vessels for angina to develop. Angina pectoris is especially severe if two or three coronary vessels are affected simultaneously. With myocardial infarction, necrosis of muscle fibers occurs already in the first 5-6 hours after a painful attack. 8-10 days after myocardial infarction, a large number of newly formed capillaries appear. Since this time, it has been rapidly developing in areas of necrosis. connective tissue. From this moment, scarring begins in areas of necrosis. In 3-4 months.
1.3 SymptomsAndsignsischemicillnesseshearts
The first signs of IHD, as a rule, are painful sensations - that is, the signs are purely subjective. The reason for contacting a doctor should be any unpleasant sensation in the heart area, especially if it is unfamiliar to the patient. The patient should also be suspected of ischemic heart disease if pain in the chest area occurs during physical or emotional stress and goes away with rest and has the character of an attack.
The development of IHD lasts for decades; during the progression of the disease, its forms may change and, accordingly, clinical manifestations and symptoms. Therefore, we will look at the most common symptoms of IHD. However, it should be noted that about one third of patients with coronary artery disease may not experience any symptoms of the disease at all, and may not even know about its existence. Others may be bothered by symptoms of ischemic heart disease such as pain in the chest, in the left arm, in lower jaw, in the back, shortness of breath, nausea, excessive sweating, palpitations or irregular heart rhythms.
As for the symptoms of such a form of coronary heart disease as sudden cardiac death: a few days before the attack, a person develops paroxysmal discomfort in the chest, psychoemotional disorders and fear are often observed near death. Symptoms sudden cardiac death: loss of consciousness, respiratory arrest, absence of pulse in large arteries (carotid and femoral); absence of heart sounds; dilated pupils; appearance of a pale gray skin tone. During an attack, which often occurs at night during sleep, brain cells begin to die 120 seconds after it begins. After 4-6 minutes, irreversible changes in the central nervous system. After about 8-20 minutes the heart stops and death occurs.
2. Classificationcoronary heart disease
1.Sudden cardiac death(primary cardiac arrest, coronary death) - this is the most severe, lightning-fast clinical variant IHD. IHD is the cause of 85-90% of all cases of sudden death. Sudden cardiac death includes only those cases of sudden cessation of cardiac activity when death occurs in the presence of witnesses within an hour after the onset of the first threatening symptoms. Moreover, before death, the condition of the patients was assessed as stable and not causing concern.
Sudden cardiac death can be provoked by excessive physical or neuropsychic stress, but it can also occur at rest, for example, in sleep. Immediately before the onset of sudden cardiac death, approximately half of the patients experience a pain attack, which is often accompanied by the fear of imminent death. Most often, sudden cardiac death occurs in out-of-hospital conditions, which determines the most common fatal outcome of this form of coronary artery disease.
2.Angina pectoris(angina pectoris) is the most common form of ischemic heart disease. Angina pectoris is attacks of sudden onset and usually quickly disappearing chest pain. The duration of an angina attack ranges from a few seconds to 10-15 minutes. Pain most often occurs during physical stress, for example, when walking. This is the so-called angina pectoris. Less commonly, it occurs during mental work, after emotional overload, during cooling, after a heavy meal, etc. Depending on the stage of the disease, angina pectoris is divided into new-onset angina, stable angina (indicating functional class from I to IV), and progressive angina. With the further development of coronary artery disease, angina pectoris is supplemented by angina at rest, in which painful attacks occur not only during exertion, but also at rest, sometimes at night.
3.Heart attack myocardium- a serious disease that can develop into a prolonged attack of angina pectoris. This form of IHD is caused by acute insufficiency blood supply to the myocardium, which causes a focus of necrosis, that is, tissue necrosis, to appear in it. The main reason for the development of myocardial infarction is complete or almost complete blockage of the arteries by a thrombus or swollen atherosclerotic plaque. When an artery is completely blocked by a thrombus, a so-called large-focal (transmural) myocardial infarction occurs. If the blockage of the artery is partial, then several smaller foci of necrosis develop in the myocardium, then they speak of a small-focal myocardial infarction.
Another form of manifestation of ischemic heart disease is called post-infarction cardiosclerosis. Post-infarction cardiosclerosis occurs as a direct consequence of myocardial infarction.
Post-infarction cardiosclerosis- this is damage to the heart muscle, and often to the heart valves, due to the development of scar tissue in them in the form of areas of varying size and extent that replace the myocardium. Post-infarction cardiosclerosis develops because dead areas of the heart muscle are not restored, but are replaced by scar tissue. Manifestations of cardiosclerosis often include conditions such as heart failure and various arrhythmias.
The main manifestations of cardiosclerosis are signs of heart failure and arrhythmia. The most noticeable symptom of heart failure is pathological shortness of breath that occurs with minimal physical activity, and sometimes even at rest. In addition, signs of heart failure may include increased heart rate, fatigue, and swelling caused by excess fluid retention in the body. The symptom that unites different types of arrhythmias is unpleasant sensations associated with the fact that the patient feels his heart beating. In this case, the heartbeat can be rapid (tachycardia), slow (bradycardia), the heart can beat intermittently, etc.
It should be recalled once again that coronary disease develops in a patient over many years, and the earlier the correct diagnosis is made and appropriate treatment is started, the greater the patient’s chances for full life further.
Painless ischemia myocardium is the most unpleasant and dangerous type of coronary artery disease, since, unlike attacks of angina, episodes of silent ischemia occur unnoticed by the patient. Therefore, 70% of cases of sudden cardiac death occur in patients with silent myocardial ischemia. In addition, silent ischemia increases the risk of arrhythmias and congestive heart failure. Only a cardiologist can detect silent ischemia in a patient using research methods such as long-term Holter monitoring, functional stress tests, and echocardiography. In case of timely examination and correct diagnosis, silent myocardial ischemia can be successfully treated
3. Diagnosticsischemicillnesseshearts
coronary heart disease stroke
Only a cardiologist can make a correct diagnosis of coronary heart disease using modern diagnostic methods. Such a high percentage of mortality from ischemic heart disease in the 20th century is partly explained by the fact that due to the abundance of various symptoms and frequent cases of asymptomatic course of ischemic heart disease, the diagnosis correct diagnosis was difficult. Nowadays, medicine has made a huge step forward in the methods of diagnosing coronary artery disease.
Survey patient
Of course, any diagnosis begins with interviewing the patient. The patient needs to remember as accurately as possible all the sensations in the heart area that he experiences and has experienced before, determine whether they have changed or remained unchanged for a long time, whether he has symptoms such as shortness of breath, dizziness, increased heartbeat, etc. In addition, the doctor should be interested in what diseases the patient has suffered during his life, what medications he usually takes, and much more.
Inspection patient
During the examination, the cardiologist listens possible noise in the heart, determines whether the patient has swelling or cyanosis (symptoms of heart failure)
Laboratory research
During laboratory tests, cholesterol and blood sugar levels are determined, as well as enzymes that appear in the blood during a heart attack and unstable angina.
Electrocardiogram
One of the main methods for diagnosing all cardiovascular diseases, including ischemic heart disease, is electrocardiography. The method of recording an electrocardiogram is widely used in cardiac diagnostics and is a mandatory step in the examination of a patient, regardless of the preliminary diagnosis. ECG is also used for dispensary examination, during preventive medical examinations, during tests with physical activity (for example, on a bicycle ergometer). Regarding the role of the ECG in recognizing ischemic heart disease, this examination helps to detect deviations in the functioning of the heart muscle, which can be crucial for diagnosing ischemic heart disease.
Holterovskoe monitoring ECG
Holter monitoring of the electrocardiogram is a long-term, often daily, ECG recording, which is carried out offline in a hospital or outpatient setting. In this case, the conditions for conducting the examination should be as close as possible to Everyday life the patient, both at rest and during various physical and psychological stress. This allows you to register not only the symptoms of IHD, but also the conditions and causes of their occurrence (at rest, during exercise). Holter monitoring helps the cardiologist determine the level of load at which the attack begins, after what rest period it ends, and also identify attacks of angina at rest, which often occur at night. In this way, a reliable picture of a person’s condition is created over a more or less long period of time, episodes of ischemia and heart rhythm disturbances are identified.
Load tests
Electrocardiographic stress tests are also an indispensable method for diagnosing angina pectoris. The essence of the method is to record an ECG while the patient is performing dosed physical activity. With physical activity, selected individually for each patient, conditions are created that require a high supply of oxygen to the myocardium: these are the conditions that will help identify the discrepancy between the metabolic needs of the myocardium and the ability of the coronary arteries to provide sufficient blood supply to the heart. In addition, ECG tests with physical activity can also be used to detect coronary insufficiency in people who do not present any complaints, for example, with silent myocardial ischemia. The most popular of them and the most frequently used can be considered the bicycle ergometer test, which allows you to accurately dose muscle work over a wide power range.
Functional samples
In addition, to diagnose ischemic heart disease, they are sometimes used functional tests which provoke spasm of the coronary artery. This is a cold test and a test with ergometrine. However, the first of them gives reliable results only in 15-20% of cases, and the second can be dangerous by the development of severe complications and therefore these methods are used only in specialized research institutions.
Ultrasonic study hearts. EchoCG
In recent years it has become very common ultrasonography heart - echocardiography. EchoCG makes it possible to interpret the acoustic phenomena of the beating heart and obtain important diagnostic signs in most cases. cardiac diseases, including with ischemic heart disease. For example, echocardiography reveals the degree of dysfunction of the heart, changes in the size of cavities, and the condition of the heart valves. In some patients, disturbances in myocardial contractility are not detected at rest, but arise only under conditions of increased load on the myocardium. In these cases, stress echocardiography is used - a cardiac ultrasound technique that records myocardial ischemia induced by various stress agents (for example, dosed physical activity).
4. Modernmethodstreatmentischemicillnesseshearts
Treatment of coronary artery disease involves the joint work of the cardiologist and the patient in several directions at once. First of all, you need to take care of changing your lifestyle. In addition, drug treatment is prescribed, and, if necessary, surgical treatment methods are used.
Lifestyle changes and neutralization of risk factors include mandatory smoking cessation, correction of cholesterol levels (through diet or medications), and weight loss. For patients with coronary artery disease, the so-called “Mediterranean diet” is recommended, which includes vegetables, fruits, light poultry, fish and seafood dishes.
A very important point in non-drug treatment of IHD is the fight against a sedentary lifestyle by increasing the patient’s physical activity. Of course, an indispensable condition for successful treatment of IHD is preliminary treatment for hypertension or diabetes mellitus, if the development of IHD occurs against the background of these diseases.
The goals of treatment of coronary heart disease are defined as improving the patient’s quality of life, that is, reducing the severity of symptoms, preventing the development of forms of coronary artery disease such as myocardial infarction, unstable angina, sudden cardiac death, as well as increasing the patient’s life expectancy. The initial relief of an attack of angina is carried out with the help of nitroglycerin, which has a vasodilating effect. The rest of the drug treatment for coronary heart disease is prescribed only by a cardiologist, based on the objective picture of the disease. Among the drugs that are used in the treatment of coronary artery disease, one can highlight drugs that help reduce the myocardial oxygen demand, increase the volume of the coronary bed, etc. However, the main task in the treatment of coronary artery disease - freeing blocked vessels - is practically not solved with the help of medications (in particular, sclerotic plaques are practically not destroyed by medications). Severe cases will require surgery.
Aspirin has been considered a classic remedy for the treatment of coronary artery disease for many years; many cardiologists even recommend using it prophylactically in small quantities (half/one-fourth tablet per day).
The modern level of cardiology has a diverse arsenal of medications aimed at treating various forms of coronary artery disease. However, any medications can only be prescribed by a cardiologist and can only be used under the supervision of a doctor.
In more severe cases of coronary artery disease, surgical treatment methods are used. Enough good results shows coronary bypass surgery, when an artery blocked by a plaque or thrombus is replaced by an “artificial vessel” that takes over the blood flow. These operations are almost always performed on a non-functioning heart with artificial circulation; after bypass surgery the patient has to recover for a long time from extensive surgical trauma. The bypass method has many contraindications, especially in patients with weakened bodies, but if the operation is successful, the results are usually good.
The most promising treatment method for ischemic heart disease is currently Endovascular surgery (X-ray surgery) is considered. The term “endovascular” translates as “inside the vessel.” This relatively young area of medicine has already gained a strong position in the treatment of coronary artery disease. All interventions are performed without incisions, through punctures in the skin, under X-ray observation; local anesthesia is sufficient for the operation. All these features are most important for those patients for whom traditional surgical intervention is contraindicated due to concomitant diseases or general weakness of the body. Among the methods of endovascular surgery for coronary artery disease, balloon angioplasty and stenting are most often used, which make it possible to restore patency in arteries affected by ischemia. When using balloon angioplasty, a special balloon is inserted into the vessel, and then it is inflated and “pushes” atherosclerotic plaques or blood clots to the sides. After this, a so-called stent is inserted into the artery - a mesh tubular frame made of “medical” stainless steel or alloys of biologically inert metals, capable of independently expanding and maintaining the shape given to the vessel.
Treatment of coronary heart disease primarily depends on the clinical form. For example, although some general principles of treatment are used for angina and myocardial infarction, treatment tactics, selection of activity regimens and specific medications may differ radically. However, it is possible to identify some general areas that are important for all forms of IHD.
1. Limitation physical loads. During physical activity, the load on the myocardium increases, and as a result, the myocardium’s need for oxygen and nutrients. If the blood supply to the myocardium is disrupted, this need is unsatisfied, which actually leads to manifestations of coronary artery disease. Therefore, the most important component of the treatment of any form of coronary artery disease is limiting physical activity and gradually increasing it during rehabilitation.
2. Diet. In case of coronary artery disease, in order to reduce the load on the myocardium, the intake of water and sodium chloride (table salt) is limited in the diet. In addition, given the importance of atherosclerosis in the pathogenesis of coronary artery disease, much attention is paid to limiting foods that contribute to the progression of atherosclerosis. An important component of the treatment of coronary artery disease is the fight against obesity as a risk factor.
The following food groups should be limited, or if possible avoided.
Animal fats (lard, butter, fatty meats)
· Fried and smoked foods.
· Products containing a large amount of salt (salted cabbage, salted fish, etc.)
· Limit intake of high-calorie foods, especially quickly absorbed carbohydrates. (chocolate, candy, cakes, pastry).
To correct body weight, it is especially important to monitor the ratio of energy coming from the food eaten and energy expenditure as a result of the body’s activities. For sustainable weight loss, the deficit must be at least 300 kilocalories daily. On average, a person not engaged in physical work spends 2000-2500 kilocalories per day.
3. Pharmacotherapy at IHD. There are a number of groups of drugs that may be indicated for use in one form or another of coronary artery disease. In the USA there is a formula for the treatment of coronary artery disease: “A-B-C”. It involves the use of a triad of drugs, namely antiplatelet agents, beta-blockers and hypocholesterolemic drugs.
Also, in the presence of concomitant hypertension, it is necessary to ensure that target blood pressure levels are achieved.
Antiplatelet agents (A). Antiplatelet agents prevent the aggregation of platelets and red blood cells, reduce their ability to glue and adhere to the vascular endothelium. Antiplatelet agents facilitate the deformation of red blood cells when passing through capillaries and improve blood fluidity.
· Aspirin - taken once a day in a dose of 100 mg; if myocardial infarction is suspected, a single dose can reach 500 mg.
· Clopidogrel - taken once a day, 1 tablet of 75 mg. It is required to take it for 9 months after endovascular interventions and CABG.
B-blockers (B). Due to their action on β-arenoceptors, adrenergic blockers reduce the heart rate and, as a result, myocardial oxygen consumption. Independent randomized studies confirm an increase in life expectancy when taking beta-blockers and a decrease in the incidence of cardiovascular events, including recurrent ones. Currently, it is not advisable to use the drug atenolol, since according to randomized studies it does not improve the prognosis. β-blockers are contraindicated in case of concomitant pulmonary pathology, bronchial asthma, COPD. Below are the most popular beta-blockers with proven properties of improving the prognosis of coronary artery disease.
· Metoprolol (Betalok Zok, Betalok, Egilok, Metocard, Vasocardin);
· bisoprolol (Concor, Coronal, Bisogamma, Biprol);
Carvedilol (Dilatrend, Talliton, Coriol).
- Statins and Fibrates (C). Cholesterol-lowering drugs are used to reduce the rate of development of existing atherosclerotic plaques and prevent the formation of new ones. A positive effect on life expectancy has been proven, and these drugs also reduce the frequency and severity of cardiovascular events. The target cholesterol level in patients with coronary artery disease should be lower than in persons without coronary artery disease and equal to 4.5 mmol/l. The target LDL level in patients with coronary artery disease is 2.5 mmol/l.
· lovastatin;
· simvastatin;
· atorvastatin;
Rosuvastatin (the only drug that significantly reduces the size of atherosclerotic plaque);
Fibrates. They belong to a class of drugs that increase the antiatherogenic fraction of HDL, with a decrease in which the mortality rate from coronary artery disease increases. Used to treat dyslipidemia IIa, IIb, III, IV, V. They differ from statins in that they mainly reduce triglycerides (VLDL) and can increase the HDL fraction. Statins primarily reduce LDL and do not have a significant effect on VLDL and HDL. Therefore, a combination of statins and fibrates is required to most effectively treat macrovascular complications. With the use of fenofibrate, mortality from coronary artery disease is reduced by 25%. Of the fibrates, only fenofibrate is safely combined with any class of statins (FDA).
fenofibrate
Other classes: omega-3 polyunsaturated fatty acids (Omacor). In case of ischemic heart disease, they are used to restore the phospholipid layer of the cardiomyocyte membrane. By restoring the structure of the cardiomyocyte membrane, Omacor restores the basic (vital) functions of cardiac cells - conductivity and contractility, which were impaired as a result of myocardial ischemia.
Nitrates. There are nitrates for injection.
Drugs in this group are derivatives of glycerol, triglycerides, diglycerides and monoglycerides. The mechanism of action is the influence of the nitro group (NO) on the contractile activity of vascular smooth muscles. Nitrates predominantly act on the venous wall, reducing the preload on the myocardium (by dilating the vessels of the venous bed and deposition of blood). A side effect of nitrates is a decrease in blood pressure and headaches. Nitrates are not recommended for use if blood pressure is below 100/60 mmHg. Art. In addition, it is now reliably known that taking nitrates does not improve the prognosis of patients with coronary artery disease, that is, it does not lead to an increase in survival, and are currently used as a drug to relieve the symptoms of angina pectoris. Intravenous drip administration of nitroglycerin can effectively combat the symptoms of angina pectoris, mainly against the background of high blood pressure numbers.
Nitrates exist in both injectable and tablet forms.
· nitroglycerin;
isosorbide mononitrate.
Anticoagulants. Anticoagulants inhibit the appearance of fibrin filaments, they prevent the formation of blood clots, help stop the growth of existing blood clots, and enhance the effect of endogenous enzymes that destroy fibrin on blood clots.
· Heparin (the mechanism of action is due to its ability to specifically bind to antithrombin III, which sharply increases the inhibitory effect of the latter in relation to thrombin. As a result, the blood clots more slowly).
Heparin is injected under the skin of the abdomen or using an infusion pump intravenously. Myocardial infarction is an indication for heparin prophylaxis of blood clots; heparin is prescribed at a dose of 12,500 IU, injected under the skin of the abdomen daily for 5-7 days. In the ICU, heparin is administered to the patient using an infusion pump. The instrumental criterion for prescribing heparin is the presence of depression of the S-T segment on the ECG, which indicates an acute process. This sign is important in terms of differential diagnosis, for example, in cases where the patient has ECG signs of previous heart attacks.
Diuretics. Diuretics are designed to reduce the load on the myocardium by reducing the volume of circulating blood due to the accelerated removal of fluid from the body.
Loopbacks. The drug "Furosemide" in tablet form.
Loop diuretics reduce the reabsorption of Na +, K +, Cl - in the thick ascending part of the loop of Henle, thereby reducing the reabsorption (reabsorption) of water. They have a fairly pronounced rapid effect, and are usually used as emergency drugs (for forced diuresis).
The most common drug in this group is furosemide (Lasix). Available in injection and tablet forms.
Thiazide. Thiazide diuretics are Ca 2+ sparing diuretics. By reducing the reabsorption of Na + and Cl - in the thick segment of the ascending limb of the loop of Henle and the initial part of the distal tubule of the nephron, thiazide drugs reduce urine reabsorption. With systematic use of drugs in this group, the risk of cardiovascular complications in the presence of concomitant hypertension is reduced.
· hypothiazide;
· indapamide.
Inhibitorsangiotensin-convertingenzyme. By acting on the angiotensin-converting enzyme (ACE), this group of drugs blocks the formation of angiotensin II from angiotensin I, thus preventing the effects of angiotensin II, that is, leveling vasospasm. This ensures that target blood pressure levels are maintained. Drugs in this group have nephro- and cardioprotective effects.
Enalapril;
Lisinopril;
captopril
Antiarrhythmicdrugs. The drug "Amiodarone" is available in tablet form.
· Amiodarone belongs to group III antiarrhythmic drugs and has a complex antiarrhythmic effect. This drug acts on the Na + and K + channels of cardiomyocytes, and also blocks b- and b-adrenergic receptors. Thus, amiodarone has antianginal and antiarrhythmic effects. According to randomized clinical trials, the drug increases the life expectancy of patients who regularly take it. When taking tablet forms of amiodarone, the clinical effect is observed after approximately 2-3 days. The maximum effect is achieved after 8-12 weeks. This is due to the long half-life of the drug (2-3 months). In this regard, this drug is used for the prevention of arrhythmias and is not an emergency treatment.
Taking into account these properties of the drug, the following scheme of its use is recommended. During the saturation period (the first 7-15 days), amiodarone is prescribed at a daily dose of 10 mg/kg of the patient’s weight in 2-3 doses. With the onset of a persistent antiarrhythmic effect, confirmed by the results of daily ECG monitoring, the dose is gradually reduced by 200 mg every 5 days until a maintenance dose of 200 mg per day is reached.
Othergroupsdrugs.
Ethylmethylhydroxypyridine
The drug "Mexidol" in tablet form. Metabolic cytoprotector, antioxidant-antihypoxant, which has a complex effect on the key links in the pathogenesis of cardiovascular disease: anti-atherosclerotic, anti-ischemic, membrane-protective. Theoretically, ethylmethylhydroxypyridine succinate has significant beneficial effects, but at present there is no data on its clinical effectiveness based on independent randomized placebo-controlled studies.
· Mexico;
· coronator;
· trimetazidine.
4. Usage antibiotics at IHD. There are results of clinical observations of the comparative effectiveness of two different courses of antibiotics and placebo in patients admitted to the hospital with either acute myocardial infarction or unstable angina. Studies have shown the effectiveness of a number of antibiotics in the treatment of coronary artery disease. The effectiveness of this type of therapy is not pathogenetically substantiated, and this technique is not included in the standards of treatment for coronary artery disease.
5. Endovascular Coronary angioplasty. The use of endovascular (transluminal, transluminal) interventions (coronary angioplasty) for various forms of coronary artery disease is developing. Such interventions include balloon angioplasty and stenting under the guidance of coronary angiography. In this case, instruments are inserted through one of the large arteries (in most cases the femoral artery is used), and the procedure is performed under fluoroscopic control. In many cases, such interventions help prevent the development or progression of myocardial infarction and avoid open surgery.
This area of treatment of coronary artery disease is dealt with in a separate field of cardiology - interventional cardiology.
6. Surgical treatment.
Aorto-coronary bypass surgery is performed.
Under certain conditions of coronary heart disease, indications for coronary artery bypass surgery arise - an operation in which the blood supply to the myocardium is improved by connecting the coronary vessels below the site of their lesion with external vessels. The best known is coronary artery bypass grafting (CABG), in which the aorta is connected to segments of the coronary arteries. For this purpose, autografts (usually the great saphenous vein) are often used as shunts.
It is also possible to use balloon dilatation of blood vessels. During this operation, a manipulator is inserted into the coronary vessels through a puncture of an artery (usually the femoral or radial), and using a balloon filled with a contrast agent, the lumen of the vessel is expanded; the operation is, in essence, bougienage of the coronary vessels. Currently, “pure” balloon angioplasty without subsequent stent implantation is practically not used, due to its low effectiveness in the long term.
7. Other non-medicinal methods treatment
- Hirudotherapy. Hirudotherapy is a treatment method based on the use of the antiplatelet properties of leech saliva. This method is an alternative and has not been clinically tested to meet the requirements of evidence-based medicine. Currently, it is used relatively rarely in Russia, is not included in the standards of medical care for coronary artery disease, and is used, as a rule, at the request of patients. Potential beneficial effects of this method include the prevention of blood clots. It is worth noting that when treated according to approved standards, this task is performed using heparin prophylaxis.
- Methodshock wavetherapy. Exposure to low power shock waves leads to myocardial revascularization.
An extracorporeal source of focused acoustic wave allows remote influence on the heart, causing “therapeutic angiogenesis” (vascular formation) in the zone of myocardial ischemia. Exposure to UVT has a double effect - short-term and long-term. First, the vessels dilate and blood flow improves. But the most important thing begins later - new vessels appear in the affected area, which provide long-term improvement.
Low-intensity shock waves cause shear stress in the vascular wall. This stimulates the release of vascular growth factors, triggering the growth of new vessels that feed the heart, improving myocardial microcirculation and reducing angina. The results of such treatment are theoretically a decrease in the functional class of angina, an increase in exercise tolerance, a decrease in the frequency of attacks and the need for medications.
However, it should be noted that at present there have been no adequate independent multicenter randomized studies evaluating the effectiveness of this technique. Studies cited as evidence of the effectiveness of this technique are usually carried out by the manufacturing companies themselves. Or do not meet the criteria of evidence-based medicine.
This method is not widely used in Russia due to questionable effectiveness, high cost of equipment, and lack of appropriate specialists. In 2008, this method was not included in the standard of medical care for coronary artery disease, and these manipulations were carried out on a contractual commercial basis, or in some cases under voluntary health insurance contracts.
- Usagestemcells. When using stem cells, those performing the procedure expect that the pluripotent stem cells introduced into the patient’s body will differentiate into the missing cells of the myocardium or vascular adventitia. It should be noted that stem cells actually have this ability, but at present the level of modern technology does not allow us to differentiate a pluripotent cell into the tissue we need. The cell itself makes the choice of differentiation path - and often not the one needed for the treatment of coronary artery disease.
This treatment method is promising, but has not yet been clinically tested and does not meet the criteria of evidence-based medicine. It takes years of scientific research to achieve the effect that patients expect from the introduction of pluripotent stem cells.
Currently, this treatment method is not used in official medicine and is not included in the standard of care for IHD.
- QuantumtherapyIHD. It is a therapy using laser radiation. The effectiveness of this method has not been proven, and no independent clinical study has been conducted.
Posted on Allbest.ru
...Similar documents
Classification of coronary heart disease: sudden coronary death, angina pectoris, myocardial infarction, cardiosclerosis. Identification of risk factors. Pathogenesis of coronary heart disease. Research of the cardiovascular system. Treatment of myocardial infarction.
abstract, added 06/16/2009
Prevalence of clinical forms of coronary heart disease, gender, age and psychological aspects of heart disease. Development of a psychocorrection program to improve the psychological well-being of people with coronary heart disease.
thesis, added 11/20/2011
Classification, clinical picture of manifestations of coronary heart disease. The importance of genetic factors in the development of coronary heart disease. Methods of diagnosis, treatment. Lifestyle modification. The role of the paramedic in the prevention of coronary heart disease.
thesis, added 05/28/2015
Classification of coronary heart disease. Risk factors for the development of coronary artery disease. Angina pectoris: clinic; differential diagnosis. Relieving an attack of angina. Treatment during the interictal period. Medical nutrition with ischemic heart disease. Prevention of coronary heart disease.
test, added 03/16/2011
Etiology and pathogenesis of atherosclerosis, its clinical course, treatment features. The main signs of coronary heart disease. Classification of types of disease. Angina pectoris is the mildest form of coronary artery disease. Symptoms of the disease, drugs and treatment.
presentation, added 04/01/2011
The main symptom of ischemic disease. Clinic of the syndrome, development mechanisms (pathogenesis). Diagnostic criteria, excluding angina pectoris. Studying the awareness of different age groups of the population about the first symptoms of coronary heart disease.
course work, added 04/21/2015
Classification of coronary heart disease. Basic organic nitrates and groups of antianginal agents. Pharmacodynamics of nitrates and their effect on coronary circulation. Development of tolerance (addiction) to nitrates, methods of prevention.
presentation, added 10/21/2013
The influence of risk factors on the development of coronary heart disease, its forms (angina pectoris, myocardial infarction) and complications. Atherosclerosis as the main cause of the development of coronary heart disease. Diagnosis and principles of drug correction of disorders.
test, added 02/22/2010
The concept of coronary heart disease, its types, symptoms, treatment and prevention. Causes of impaired blood flow in the coronary arteries. Incidence of cardiovascular diseases in Russia and mortality from them. Factors influencing predisposition.
course work, added 04/07/2015
Symptoms of coronary heart disease (CHD). Traditional instrumental methods for diagnosing ischemic heart disease. Electrocardiography (ECG) at rest, 24-hour Holter ECG monitoring. Diagnostic capabilities of echocardiography. Stress tests, coronary angiography.