Why is coronary heart disease dangerous? Coronary heart disease: symptoms, causes, treatment, prognosis and prevention. What methods of surgical treatment exist?

IHD is one of the vascular diseases that directly affects the functioning of the heart. What is coronary heart disease, what practical recommendations and knowledge are necessary to combat the disease, everyone suffering from ischemia should know. Exacerbation of ischemia pose a serious threat to the patient's life. This condition is called acute coronary death and develops suddenly and like an avalanche. Breathing stops, the heart stops working, and the person loses consciousness. Even with timely and qualified assistance, about 60% of cases end in death. Therefore, it is so important to diagnose the initial stage of the disease in time and undergo appropriate treatment.

What is coronary heart disease and its cause

The disease is caused by a systematic, constant lack of sufficient oxygen in the heart. The latter, as is known, enters the organs with blood. If for some reason blood circulation is impaired, then an acute lack of oxygen develops (hypoxia). In the case of the disease in question, the coronary arteries are responsible for the disruption of the blood supply to the heart muscle. The following factors can lead to disruption of these vessels’ functions.

1. Aneurysm of the thoracic aorta. It interferes with the proper functioning of the valve between the aorta and the heart.
2. Inflammation of the coronary arteries occurring in systemic connective tissue diseases (arteritis). Inflammatory processes lead to a narrowing of the blood flow channel.
3. Cardiovascular syphilis. Damage to the coronary arteries and aorta, a complication against the background of a known venereal disease.
4. Thrombosis and embolism. Changes in the composition of the blood often lead to the formation of blood clots and blockage of blood vessels.
5. Atherosclerosis of the artery walls. The main cause of coronary heart disease. With this pathology, the lumen in the vessel narrows significantly, which complicates the passage of blood flow.
6. Congenital abnormalities in the structure of the coronary arteries. Some heart defects can also form in utero.
7. Hereditary predisposition to the disease. As a rule, most people suffering from ischemia have one or more older direct relatives who are familiar with this problem.

Risk factors

Quite often, active smokers with many years of experience are diagnosed with coronary heart disease. Tobacco smoke tends to narrow all blood vessels in the body, including those located in the heart area. Physical inactivity (lack of physical activity) can significantly worsen the condition of blood vessels. The risk is also high for those suffering from diabetes mellitus, due to disturbances in carbohydrate metabolism in the body.

In adulthood, blood vessels gradually lose their quality, so the risk of the disease increases with age.

A particular predisposition to the disease has been noted in overweight people. As a rule, this category includes lovers of fried, fatty and salty foods. Salt, as a chemical substance, itself contributes to the occurrence of atherosclerosis. Saturated fats speed up the process. Since the main cause of coronary heart disease is vascular sclerosis, overweight people are most susceptible to this disease.

Types of disease

There are two main types of coronary heart disease according to localization: external and internal. Accordingly, in the latter option, the inner wall of the myocardium (heart muscle) suffers from hypoxia, in the first – the outer one. The lack of blood supply to the outer wall is called subepicardial ischemia, and the same process inside is called « subendocardial myocardial ischemia ».

Typically, the outer layer of the myocardium receives a stronger blood flow, and its arteries have a greater ability to self-regulate. Subepicardial disorders occur much less frequently, and often after internal myocardial damage. The greater susceptibility of the inner walls is also explained by the fact that nutrition in this part of the heart muscle occurs due to thinner vessels, which also receive constant impact from the contracting muscles of the heart.

Symptoms

The main symptom of ischemia is angina (pressing pain in the chest, often accompanied by a burning sensation). Painful sensations occur in paroxysms, at certain intervals. At first, such attacks do not occur often, and the patient may not pay attention to them. But over time they become more frequent and intensified. The following signs may indicate the presence of ischemia:

• dyspnea;
• weakness
• nausea;
• radiating pain to the left arm, neck or between the shoulder blades.

Due to rapid fatigue, increased sweating may occur. If such signs appear, you should visit a cardiologist's office. But sometimes there is hidden ischemia, the signs of which practically do not appear. This is a special type of pathology, which is classified into several types.

1. Typical for patients with coronary stenosis, without symptoms of angina or arrhythmia.
2. It is diagnosed in the presence of a history of heart attacks without its main precursor – angina pectoris.
3. There are pain signs without characteristic additional symptoms (pain, shortness of breath, etc.).

Often the reason for the absence of pain is a high pain threshold, when a person is not sensitive to any kind of pain, including in the heart area. Silent ischemia is the most dangerous in terms of timely diagnosis, since the patient’s lack of reasons for timely access to a medical facility can lead to significant progression of the disease. This is why latent coronary heart disease is dangerous.

Diagnostics

Preliminary conclusions about the disease are made on the basis of an initial examination of the patient, which consists of several stages.

1. Recording patient complaints in order to determine directions for further research.
2. A detailed survey of the patient makes it possible to determine whether he belongs to any risk group for the disease.
3. Physical examination includes visual examination of the patient, palpation and listening with a phonendoscope.

If the data obtained is positive and there is a suspicion of heart pathology, then the research continues.

For a more accurate diagnosis, echocardiography is used, which can use ultrasound cardiography to assess the condition of the myocardium, as well as the well-known ultrasound. No less reliable is Holter monitoring, the essence of which is the collection of ECG data at different times during the day. Ischemia on an ECG is diagnosed using a special portable device that takes readings and stores them for interpretation. Electrocardiogram readings give an idea of ​​what type of disease is bothering the patient.

1. If the symmetrical T wave is below the zero line, then we can talk about ischemia of the subepicardial type, the anterior region.
2. If the positive T wave is wide, this indicates the presence of subepicardial ischemia in the lower region of the myocardium.
3. Subendocardial ischemia on the ECG appears as a sharp T wave, symmetrical and with a significant height above the zero line.

Treatment

For effective treatment, it is necessary not only to restore blood supply to the myocardium, but also to prevent the occurrence of possible complications. Therefore, therapy involves the use of drugs of various types.

Nitrates

Drugs from this group can quickly dilate blood vessels and relieve the symptoms of angina. They have a high hypotensive effect, so they must be taken in strictly dosage. These include:

• Nitroglycerine;
• Nitrogranulong;
• Corvalment;
• Korvaltab.

Nitroglycerin can cause a headache, so immediately after taking it, it is better to put a Validol tablet under your tongue.

B – adrenergic blockers

They are one of the most important components of complex treatment of ischemia, due to their properties to effectively promote the supply of oxygen to the heart muscle. Bisoprolol and Metoprolol are most often prescribed. They are prescribed only by prescription, as they have a lot of contraindications, especially for those suffering from certain diseases of the lungs and respiratory tract.

Antiplatelet agents

They normalize blood circulation by thinning the blood and prevent blood clots. Their use allows you to avoid such serious complications as myocardial infarction and acute coronary insufficiency. These include:

• Aspirin;
• Ticlopidine;
• Pentoxifylline.

The effectiveness of treatment of coronary heart disease largely depends on the timely removal of fluid from the body, which makes it possible to more effectively reduce blood pressure. Diuretics are used for this purpose:

• Hypothiazide;
• Dibazol.

General cardiac medications

This type of medication is used in complex treatment and is prescribed to increase the functionality of the cardiovascular system. One of their advantages is to supply the heart muscle with the microelements necessary for its work. For example:

• Asparkam;
• Digoxin;
• Verapamil.

Vitamins are also necessary for the functioning of the heart, especially during the period of treatment and recovery. The vitamin complex improves heart function, improves immunity and overall metabolism. The most used here is Riboxin, which is often called the heart vitamin.

Medicines may have contraindications or be incompatible, so they must be prescribed by the attending physician. Only he can always be sure that such a drug is applicable for coronary heart disease and can give recommendations on its use.

If drug therapy does not bring the desired result, then one of the surgical treatment methods is prescribed.

1. Stenting.
2. Coronary bypass surgery.
3. Coronary artery bypass surgery.

Also, if necessary, surgery may be prescribed to remove blood clots.

Treatment of cardiac ischemia with traditional methods

Like traditional drugs, traditional medicine has different directions in the treatment of one disease.

1. A tincture is perfect for relieving pain. To prepare it you will need valerian root, yarrow herb, hop cones and hawthorn flowers in a ratio of 2:2:1:3. Brew a tablespoon of the mixture with 200 g of boiling water, cover and let it brew for 15-20 minutes. Consume the contents during the day in three equal portions, half an hour before meals.
2. To relieve symptoms of arrhythmia, you can prepare an infusion of dry lovage powder. One tsp. Pour a glass of boiling water over the powder and leave for 4 hours. Take before meals throughout the day.
3. Cardiac glycosides, which are contained in sufficient quantities in Adonis and spring adonis, will be useful as a diuretic. An infusion based on them also has a calming effect.
4. To calm down and sleep well, a collection of lemon balm, rose hips, oregano, chamomile and linden flowers helps a lot. A tincture of these components is consumed half a glass, 3 times a day before meals.

For coronary heart disease, folk remedies cannot be used as independent treatment, but only as an addition to the main therapy. It is possible and necessary to be treated with herbal infusions and decoctions, but only after consultation with your doctor. This is also important because a person, in addition to ischemia, may have another disease for which there are contraindications to the use of one or another drug.

Nutritional Features

Nutrition for angina pectoris and coronary heart disease involves excluding excessive consumption of sugars and saturated fats of animal origin from the diet. Salt negatively affects blood vessels and retains water in the body. This leads to increased blood pressure, and hypertension is one of the most common companions of ischemia. You should also reduce the amount of fried foods.

For ischemia, it is much preferable to eat boiled or steamed foods. Food products should contain iron, zinc and vitamins. It is useful to add foods to your diet such as:

• cereals;
• nuts;
• legumes;
• fruits and vegetables.

During the course of treatment, the consumption of bread during the day should not exceed 250 g. Rye bread and bran are preferable. Only the white is used in eggs because the yolk is high in cholesterol. You need to eat in small portions, if possible every 3 hours.

Successful treatment of coronary artery disease is possible only if all conditions are met and depends on various circumstances. This includes the correctness of the chosen treatment and the degree of neglect of the disease. But there is a factor that depends only on the patient himself - this is a responsible attitude towards one’s health. The body has enormous self-healing abilities; you just need to not interfere with it. If you set aside enough time for rest and sleep, don’t poison your body with cigarettes and don’t take everything to heart, then your heart will respond with great gratitude.

3. TREATMENT

3.1. General principles

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

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

3.2. Modification of avoidable risk factors and education

3.2.1.Information and training

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

The patient is told in a form accessible to him about the essence of IHD and the characteristics of the clinical form of the disease identified in him. It should be emphasized that with proper adherence to medical recommendations, the symptoms of the disease can be controlled, thus improving the quality and length of life and maintaining ability to work.

The prospects for medical and surgical treatment of the form of coronary artery disease identified in him should be discussed with the patient, as well as the need and frequency of further instrumental and laboratory studies.

Patients are told about the typical symptoms of the disease, and are taught to correctly take planned and emergency drug therapy to prevent and relieve angina attacks. It is imperative to tell the patient about the possible side effects of the medications prescribed to him and possible drug interactions.

They also talk about the indications for calling an ambulance and visiting a doctor at the clinic. They remind you of the need to always have a fast-acting nitroglycerin preparation with you (in tablets or in the form of an aerosol), as well as to regularly replace expired drugs with fresh ones. The patient should keep recorded ECGs at home for comparison with subsequent recordings. It is also useful to store at home copies of extracts from hospitals and sanatoriums, the results of studies conducted and a list of previously prescribed medications.

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

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

• Immediate use of aspirin and nitroglycerin (preferably in a sitting position);
• Ways to seek emergency medical help;
• Address and telephone numbers of the nearest medical hospital with 24-hour cardiology service.

3.2.2.Smoking cessation

Stopping smoking for a patient with coronary artery disease is one of the tasks of the attending physician. Studies have shown that even simple advice from a doctor in many cases helps a patient quit smoking. To help a patient cope with a bad habit, the doctor must:

• ask about smoking history;
• assess the degree of nicotine addiction and the patient’s desire to quit smoking;
• help the patient create a smoking cessation plan (if necessary, do this together with him);
• discuss with the patient the dates and timing of subsequent follow-up visits;
• if necessary, invite close relatives of the patient and have a conversation with them in order to provide support for family members in quitting smoking.

If there is no effect from educational work, nicotine replacement therapy can be used. The drugs bupropion (Velbitrin, Zyban) and varenicline, used to treat nicotine addiction, are considered effective and relatively safe when prescribed to patients with coronary artery disease, but varenicline can provoke an exacerbation of angina pectoris.

3.2.3.Diet and body weight control.

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

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

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

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

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

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

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

Obesity is often combined with a condition such as sleep apnea - stopping breathing during sleep. Patients suffering from sleep apnea have an increased risk of developing severe complications of coronary artery disease and coronary death. Today, there are methods for treating sleep apnea using the CPAP therapy method (from the English Constant Positive Airway Pressure, CPAP), during which constant positive pressure is created in the patient’s airways, preventing breathing cessation during sleep. If sleep apnea is detected in a patient with coronary artery disease and excess weight, it is recommended to refer him to a medical facility that provides CPAP therapy.

3.2.4.Physical activity

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

Dosed physical activity is especially useful for patients with obesity and diabetes mellitus, because against the background of physical exercise, their carbohydrate and lipid metabolism improves.

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

3.2.5.Sexual activity

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

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

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

3.2.6.Correction of dyslipidemia

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

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

Other drugs that correct lipid metabolism disorders and are registered in Russia include fibrates, nicotinic acid and omega 3 PUFAs. Fibrates are prescribed to patients with severe hypertriglyceridemia, mainly to prevent pancreatitis. It has been shown that in patients with type II diabetes, the administration of fenofibrate to persons with elevated TG levels and reduced HDL cholesterol levels leads to a reduction in cardiovascular complications by 24%, which is the basis for recommending fenofibrate to this category of patients. Omega 3 PUFAs in a dose of 4-6 g have a hypotriglyceridemic effect and are a second-line treatment after fibrates for the correction of hypertriglyceridemia. Nicotinic acid, as well as bile acid sequestrants, in a dosage form acceptable for the correction of dyslipidemia, are currently not available on the Russian pharmaceutical market.

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

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

3.2.7.Arterial hypertension

Elevated blood pressure is the most important risk factor for the development of atherosclerosis and complications of coronary artery disease. The main goal of treatment for patients with hypertension is defined in the National Recommendations of the GFOC and RMOAG [1] and is to minimize the risk of developing cardiovascular complications and death from them.

When treating patients with coronary artery disease and hypertension, the blood pressure level should be less than 140/90 mm Hg

3.2.8. Disorders of carbohydrate metabolism, diabetes mellitus.

Disorders of carbohydrate metabolism and diabetes increase the risk of cardiovascular complications in men by 3 times, in women by 5 times compared to persons without diabetes. Issues of diagnosis and treatment of diabetes are discussed in special guidelines. In this category of patients, control of the main risk factors, including blood pressure, dyslipidemia, excess weight, low physical activity, smoking, should be carried out with special care:

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

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

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

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

HbA1c* – glycated hemoglobin

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

3.2.9.Psychosocial factors

Anxiety and depressive disorders are common in patients with coronary artery disease; many of them are exposed to stress factors. In case of clinically pronounced disorders, patients with coronary artery disease should be consulted by specialists. Antidepressant therapy significantly reduces symptoms and improves quality of life, but there is currently no rigorous evidence that such treatment reduces the risk of cardiovascular events.

3.2.10 Cardiac rehabilitation

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

3.2.11.Vaccination against influenza

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

3.2.12. Hormone replacement therapy

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

3.3. Drug treatment

3.3.1 Drugs that improve the prognosis for chronic ischemic heart disease:

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

3.3.1.1. Antiplatelet agents

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

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

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

The third generation thienopyridine - prasugrel, as well as a drug with a reversible mechanism of P2Y12 receptor blockade - ticagrelor, cause a stronger inhibition of platelet aggregation compared to clopidogrel. These drugs are more effective than clopidogrel in the treatment of patients with acute coronary syndromes. There have been no clinical studies examining prasugrel and ticagrelor in patients with stable coronary artery disease.

Dual antiplatelet therapy. Combination antiplatelet therapy, including aspirin and a thienopyridine (clopidogrel), is the standard of care for patients who have experienced ACS, as well as for patients with stable coronary artery disease undergoing elective percutaneous coronary intervention (PCI).

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

Thus, dual antiplatelet therapy has benefits only in certain categories of patients with a high risk of developing ischemic events. Routine administration of this therapy to patients with stable coronary artery disease is not recommended.

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

Specific to clopidogrel is the carriage of single nucleotide polymorphisms associated with decreased absorption of the drug in the intestine (ABC1 C3435T gene) or its activation in the liver (CYP2C19*2 gene). The effect of carriage of these genetic variants on the outcomes of treatment with clopidogrel has been proven for patients with ACS undergoing invasive treatment; there are no similar data for patients with stable coronary artery disease. Therefore, a routine study of the pharmacogenetics of clopidogrel and assessment of ORT in patients with stable coronary artery disease, incl. undergoing elective PCI are not recommended.

Drugs:

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

3.3.1.2. Statins and other lipid-lowering drugs

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

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

3.3.1.3. Blockers of the renin-angiotensin-aldosterone system

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

If ACE inhibitors are intolerant, angiotensin receptor blockers are prescribed, but there is no clinical evidence of their effectiveness in patients with chronic ischemic heart disease.

Drugs:

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

3.3.2. Drugs that improve symptoms of the disease:

• Beta blockers;
• Calcium antagonists;
• Nitrates and nitrate-like drugs (molsidomine);
• Ivabradine;
• Nicorandil;
• Ranolazine;
• Trimetazidine

Since the main goal of treatment of chronic ischemic heart disease is to reduce morbidity and mortality, any drug therapy regimen for patients with organic damage to the coronary arteries and myocardium must necessarily contain drugs with a proven positive effect on the prognosis of this disease - unless a particular patient has direct contraindications to their reception.

3.3.2.1 Beta blockers

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

For the treatment of angina, beta blockers are prescribed in a minimum dose, which, if necessary, is gradually increased until angina attacks are completely controlled or the maximum dose is reached. When using beta blockers, the maximum reduction in myocardial oxygen demand and increase in coronary blood flow is achieved at a heart rate of 50-60 beats/min. If side effects occur, it may be necessary to reduce the dose of beta blockers or even discontinue them. In these cases, the prescription of other rhythm-slowing drugs, verapamil or ivabradine, should be considered. The latter, unlike verapamil, can be added to a BB if necessary to improve heart rate control and increase anti-ischemic effectiveness. The most commonly used BBs for the treatment of angina are bisoprolol, metoprolol, atenolol, nebivolol, and carvedilol. The drugs are recommended in the following doses:

• Bisoprolol orally 2.5-10 mg 1 time / day;
• Metoprolol succinate orally 100-200 mg 1 time / day;
• Metoprolol tartrate orally 50-100 mg 2 times a day (not recommended for CHF);
• Nebivolol orally 5 mg 1 time per day;
• Carvedilol orally 25-50 mg 2 times a day;
• Atenolol orally starting from 25-50 mg 1 time / day, the usual dose is 50-100 mg (not recommended for CHF).

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

3.3.2.2. Calcium antagonists

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

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

Drugs:

• Verapamil orally 120-160 mg 3 times a day;
• Long-acting verapamil 120-240 mg 2 times a day;
• Diltiazem orally 30-120 mg 3-4 times a day
• Long-acting diltiazem orally 90-180 mg 2 times a day or 240-500 mg 1 time a day.
• Long-acting nifedipine orally 20-60 mg 1-2 times a day;
• Amlodipine orally 2.5-10 mg 1 time / day;
• Felodipine orally 5-10 mg 1 time / day.

3.3.2.3. Nitrates and nitrate-like agents

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

Relieving an attack of angina. If angina occurs, the patient should stop, sit down and take a short-acting NTG or ISDN drug. The effect occurs 1.5-2 minutes after taking the tablet or inhalation and reaches a maximum after 5-7 minutes. In this case, pronounced changes in peripheral vascular resistance occur due to the dilation of veins and arteries, stroke volume of the heart and systolic blood pressure decrease, the ejection period is shortened, the volume of the ventricles of the heart is reduced, coronary blood flow and the number of functioning collaterals in the myocardium increase, which ultimately ensures the restoration of the necessary coronary blood flow and disappearance of the ischemic focus. Favorable changes in hemodynamics and vascular tone persist for 25-30 minutes - time sufficient to restore the balance between the myocardium's need for oxygen and its supply with the coronary blood flow. If the attack is not stopped within 15-20 minutes, including after repeated administration of nitroglycerin, there is a risk of developing MI.

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

Drugs:

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

Every patient with coronary artery disease should always have a fast-acting NTG with them. It is recommended to take it immediately if an attack of angina pectoris does not stop when provoking factors are excluded (physical stress, psycho-emotional stress, cold). Under no circumstances should you expect the angina attack to stop on its own. If there is no effect, NG administration can be repeated after 5 minutes, but no more than 3 times in a row. If pain persists, you must urgently call an ambulance or actively consult a doctor.

Preventing an attack of angina

To maintain a sufficient concentration in the blood for a long time, isosorbide dinitrate or isosorbide mononitrate are used, which are the drugs of choice:

Drugs:

• Isosorbide dinitrate orally 5-40 mg 4 times a day
• Long-acting isosorbide dinitrate orally 20-120 mg 2-3 times a day
• Isosorbide mononitrate orally 10-40 mg 2 times a day
• Long-acting isosorbide mononitrate orally 40-240 mg 1 time / day

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

Nitrates can be used in transdermal forms: ointments, patches and discs.

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

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

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

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

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

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

To prevent nitrate tolerance and eliminate it, intermittent intake of nitrates throughout the day is recommended; taking nitrates with an average duration of action 2 times a day, long-acting nitrates - 1 time a day; alternative therapy to molsidomine.

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

• Molsidomine orally 2 mg 3 times a day
• Extended-release molsidomine orally 4 mg 2 times a day or 8 mg 1 time a day.

3.3.2.4. Sinus node inhibitor ivabradine

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

3.3.2.5. Potassium channel activator nicorandil

The antianginal and anti-ischemic drug nicorandil simultaneously has the properties of organic nitrates and activates ATP-dependent potassium channels. Dilates coronary arterioles and veins, reproduces the protective effect of ischemic preconditioning, and also reduces platelet aggregation. The drug, when used long-term, can help stabilize atherosclerotic plaque, and in one study it reduced the risk of cardiovascular complications. Nicorandil does not cause the development of tolerance, does not affect blood pressure, heart rate, conductivity and contractility of the myocardium. Recommended for the treatment of patients with microvascular angina (if BB and calcium antagonists are ineffective). The drug is used both to relieve and prevent angina attacks.

A drug:

• Nicorandil sublingually 20 mg to relieve angina attacks;
• Nicorandil orally 10-20 mg 3 times a day for the prevention of angina pectoris.

3.3.2.6. Ranolazine

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

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

3.3.2.7. Trimetazidine

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

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

3.3.3. Features of drug treatment of vasospastic angina

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

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

3.3.4. Features of drug treatment of microvascular angina

For this form of angina, the use of statins and antiplatelet drugs is also recommended. To prevent pain syndromes, BBs are first prescribed, and if the effectiveness is insufficient, calcium antagonists and long-acting nitrates are used. In cases of persistent angina, ACE inhibitors and nicorandil are prescribed. There is evidence of the effectiveness of ivabradine and ranolazine.

3.4. Non-drug treatment

3.4.1. Myocardial revascularization in chronic ischemic heart disease

Planned myocardial revascularization is carried out using balloon angioplasty with coronary artery stenting, or through coronary artery bypass grafting.

In each case, when deciding on revascularization for stable angina, the following must be taken into account:

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

3.4.1.1 Endovascular treatment: angioplasty and stenting of the coronary arteries

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

Stable angina is one of the most common indications for referral to BCA. It should be clearly understood that the main goal of BCA in these cases should be considered to be a reduction in the frequency or disappearance of painful attacks (angina pectoris).

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

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

In doubtful cases, indications for BCA are clarified after performing an imaging stress test (stress echocardiography or stress myocardial perfusion scintigraphy), which allows identifying the symptom-related coronary artery.

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

3.4.1.2. Coronary artery bypass grafting for chronic ischemic heart disease

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

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

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

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

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

In case of isolated lesions of the coronary arteries and variants of stenosis favorable for dilatation, both bypass surgery and angioplasty with stenting can be performed.

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

Indications and contraindications for surgical treatment of coronary artery disease are determined on a case-by-case basis.

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

3.4.2. Experimental non-drug treatment of chronic ischemic heart disease

Sympathectomy, epidural spinal electrical stimulation, intermittent urokinase therapy, transmyocardial laser revascularization, etc., are not widely used; the question of the possibilities of gene therapy still remains open. New and actively developing non-pharmacological methods for the treatment of chronic ischemic heart disease are external counterpulsation (ECP) and extracorporeal cardiac shock wave therapy (ESWT), which are considered methods of “non-invasive cardiac revascularization”.

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

Extracorporeal cardiac shock wave therapy (ESWT) is a new approach to the treatment of the most severe group of patients with chronic ischemic heart disease, ischemic cardiomyopathy and heart failure, resistant to drug therapy, when it is impossible to perform invasive myocardial revascularization (bypass surgery or BCA with stenting). The CSWT method is based on the effect on the myocardium of extracorporeally generated shock wave energy. It is assumed that this method activates coronary angioneogenesis and promotes vasodilation of the coronary arteries. The main indications for CSWT: 1) severe stable angina pectoris of class III-IV, refractory to drug treatment; 2) ineffectiveness of conventional methods of myocardial revascularization; 3) residual symptoms after myocardial revascularization; 4) widespread damage to the distal branches of the coronary arteries, 5) preservation of viable left ventricular myocardium.

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

Lack of blood supply translated from Latin is cardiac ischemia. During ischemia, blood is simply not able to pass through the coronary arteries in the required quantity due to blockage or narrowing of the latter. The heart muscle therefore does not receive the required amount of oxygen, and if treatment is not carried out on time, it no longer contracts, which, accordingly, leads to the death of the patient.

Causes

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

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

At-risk groups

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

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

Unfavorable heredity and impaired metabolism play a huge role in the development of cardiac ischemia, especially if signs of the disease appear against the background of nervous strain and lack of physical activity.

How to recognize the occurrence of IHD

Typically, the initial symptoms of cardiac ischemia appear during emotional stress or physical exertion. The heart feels as if something is squeezing it, and there is a heaviness behind the sternum. The form of the disease is determined by how severe oxygen starvation is, how quickly it occurs and how long it lasts. When treating, the following types of ischemia are distinguished:

1. A silent form (asymptomatic) of ischemia, in which no pain is experienced, and heart disease is detected after examination. Usually characteristic of the early stages of ischemia, it can occur immediately after a heart attack.
2. The arrhythmic form of ischemia is recognized by the occurrence of atrial fibrillation and other rhythm disturbances.
3. Angina pectoris, the symptoms of which usually appear during exertion, pain in the chest. Detailed sensations can also occur when overeating. An attack of angina is accompanied by squeezing, heaviness or even a burning sensation in the chest. Pain can also be felt in the left arm, forearm, neck, teeth. Often there is suffocation, darkening of the eyes, profuse sweating and weakness.

More often, angina attacks occur in the morning. These can be short manifestations of 5-10 minutes, repeated with different frequencies. The most reliable way to stop this attack is by stopping all physical activity, emotional calm, and taking nitroglycerin. If there is no result, you can use it at intervals of five minutes up to three times in a row.

Angina is also divided into two types:

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

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

When to see a doctor

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

1. At times you feel pain in the chest;
2. Breathing can sometimes be difficult;
3. You sometimes feel interruptions in the work of your heart;
4. You find it difficult to endure even small physical activities like climbing stairs;
5. You experience attacks of dizziness, shortness of breath, often feel tired, and sometimes faint;
6. The heart sometimes seems to burst out of the chest for no apparent reason.

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

Diagnosis

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

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

The last test for cardiac ischemia is performed on a special bicycle (bicycle ergometer) with sensors attached to the chest. While you pedal, a cardiologist will determine at what physical activity dangerous changes begin in your body.

In some cases, with ischemia, you may also be referred for an ultrasound (ultrasound) of the heart to check the functioning of the myocardium. The most accurate picture showing which artery is narrowed and how narrowed is provided by another study - angiography. During this procedure, a substance is injected into the bloodstream, making the coronary arteries visible during X-ray examination. As a result, the specialist determines how the blood moves through the vessels and where exactly the blockage is located.

Treatment

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

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

Sometimes other drugs, such as beta blockers, are used to treat cardiac ischemia, which lower blood pressure and slow the heart, causing it to require less oxygen. In the hospital, medications are also used to dissolve existing blood clots. Also, patients can independently use sedatives, preferably of plant origin, since it is stress that often provokes new attacks of coronary artery disease. You can use, for example, motherwort or valerian.

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

Coronary artery bypass grafting

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

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

Angioplasty

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

When the tube reaches the narrowing of the blood vessel, the balloon placed on the catheter is inflated and a stent, a spacer-like device, is placed to prevent narrowing of the blood vessel. This operation is much easier to tolerate, but it is contraindicated for patients with diabetes and those who are in the acute phase of the disease, and the vascular damage is already too severe.

Prevention of coronary disease

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

1. Stop smoking;
2. Following a diet that includes low-fat foods, eating fresh vegetables and fruits;
3. Be physically active every day, engage in physical therapy, and gradually reduce body weight;
4. Monitor blood pressure and maintain it normal;
5. Learn to effectively relieve stress through relaxation or yoga techniques.

Patients with cardiac ischemia must also have proper rest, sleeping at least 8 hours. You should not overeat, and the last meal of the day should be taken no later than 3 hours before bedtime. Spend more time in the fresh air and gradually increase the duration of your walks.

Traditional methods of preventing coronary heart disease

To avoid the occurrence of cardiac ischemia in the future or slow down its development, following traditional folk recipes is extremely useful, along with traditional treatment.

Treatment of ischemia with rose hips and hawthorn

It is very useful to drink an infusion of hawthorn and rosehip in the treatment of cardiac ischemia. The fruits should be brewed like tea, steeped for 2 hours, and half a glass should be drunk 3-4 times a day.

Rose hips can also be used for baths. Pour 500 g of rose hips into 3 liters of boiling water and simmer the mixture over low heat for ten minutes. Then it is cooled and filtered, and added to the bath. Keep the water temperature at about 38 degrees; to get a good result, you will need to carry out at least 20 procedures.

Benefits of garlic

1. Peel the medium-sized young garlic, crush it into a paste, put it in a jar;
2. Pour a glass of sunflower oil over the garlic mass and place in the refrigerator;
3. Every other day, squeeze about one tablespoon of lemon juice into a glass, add a teaspoon of prepared garlic oil and swallow the mixture.

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

Traditional recipes for the treatment of ischemia

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

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

Nutrition for IHD

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

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

Fish, on the contrary, in case of cardiac ischemia, you should choose the fattest one, for example, mackerel. Fish oil contains many important components for cholesterol metabolism. And sea fish also contains a lot of iodine, which prevents the formation of sclerotic plaques. This component is also found in abundance in seaweed. The latter also dissolves blood clots, which are the cause of blood clots.

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

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

The importance of physical activity in ischemic heart disease

In the treatment of cardiac ischemia, physical training is of no small importance. If the disease is in its initial stage, the patient is advised to swim, bike, or do not too intense cyclic loads. They should not be carried out only during periods of exacerbation.

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

is a disease that is a violation of the blood circulation of the myocardium. It is caused by a lack of oxygen, which is carried through the coronary arteries. Manifestations of atherosclerosis prevent its entry: narrowing of the lumens of blood vessels and the formation of plaques in them. In addition to hypoxia, that is, lack of oxygen, tissues are deprived of some of the beneficial nutrients necessary for the normal functioning of the heart.

Coronary artery disease is one of the most common diseases that causes sudden death. It is much less common among women than among men. This is due to the presence in the body of representatives of the fairer sex of a number of hormones that prevent the development of vascular atherosclerosis. With the onset of menopause, hormonal levels change, so the possibility of developing coronary artery disease increases sharply.

Within the classification of coronary heart disease, the following forms are distinguished:

Painless form. This myocardial ischemia is typical for people with a high pain threshold. Its development is promoted by hard physical labor and alcohol abuse. Elderly people and sick people are at risk. This form of ischemia is painless, which is why it is often called silent. However, in some cases, chest discomfort may occur. It occurs in the early stages of the disease. Characteristic symptoms of silent cardiac ischemia are tachycardia, angina pectoris, and severe. Possible weakness in the left arm, shortness of breath or.

Primary cardiac arrest. It refers to sudden coronary death. It occurs immediately after a heart attack or within a few hours after it. This manifestation of coronary heart disease is promoted by excess weight, smoking, arterial hypertension, and the cause is ventricular fibrillation. Sudden coronary death with successful resuscitation or ending in death is distinguished. In the first case, qualified medical assistance must be provided immediately. If defibrillation is not done on time, the patient dies.

Compressive or pressing pain, discomfort in the chest area - these are the main symptoms by which this form of coronary artery disease is determined. It often manifests itself in the form of heartburn, colic or nausea. Pain from the chest can radiate to the neck, left arm or shoulder on the same side, sometimes to the jaw and back areas. Discomfort occurs during active physical activity, after eating, especially when overeating, and a sharp increase in blood pressure. Angina pectoris is caused by stress and hypothermia. In all these situations, there is a need for more oxygen to the heart muscle, but due to the clogged arteries, this is not possible. To cope with the pain, which can last up to 15 minutes, it is enough to stop physical activity if it was caused by it or take short-acting nitrates. Nitroglycerin is considered the most popular among these drugs.




Angina can be stable or unstable. In the first case, it is caused by the action of environmental factors: smoking, significant physical activity. You can cope with it with the help of nitroglycerin. If it becomes ineffective, this indicates the development of unstable angina. It is more dangerous, as it often causes myocardial infarction or death of the patient. One type of unstable angina is new-onset angina. The main distinguishing feature of this form of the disease is that the onset of attacks began no later than several months ago. The cause of new-onset angina can be severe emotional or physical stress. In this case, the coronary arteries can function normally. The second group of patients consists of patients who have suffered and have pathology of the coronary arteries. If the disease develops unnoticed, there is a high probability that it will develop into stable angina. But another option is also possible. Often, the first symptoms soon disappear, the attacks stop, and over the next few years the patient does not experience any symptoms of angina. At the same time, regular examinations are required to prevent unexpected myocardial infarction.

Cardiosclerosis can be diffuse and focal. In the first case, scar tissue replaces heart cells evenly, distributed throughout the muscle. With focal cardiosclerosis, the connective tissue affects only certain areas. It is usually caused by myocardial infarction.

Plaques in the arteries cause the development of atherosclerotic cardiosclerosis. The development of myocardial cardiosclerosis is promoted by the inflammatory process directly in the heart muscle. Overeating, smoking, and a sedentary lifestyle increases the risk of developing the disease. For a long time, cardiosclerosis can be asymptomatic, especially in the case of atherosclerotic form. During rehabilitation and prevention, patients should follow a diet that involves minimal consumption of salt, fats and liquids.

There are several main symptoms of cardiac ischemia:

Pain in the chest and behind the chest area. It may have a stabbing, burning or squeezing character. Unpleasant sensations arise unexpectedly and pass after 3-15 minutes. In the first stages of coronary artery disease, discomfort may be mild. Severe pain radiates to the left arm and shoulder, less often to the jaw and right side. They appear during sports, or under strong emotional stress. To get rid of discomfort resulting from physical activity, it is enough to take a short break. When such measures do not help and the attacks become severe, they resort to the help of medications.

Dyspnea. Like pain, it first appears during movement and is caused by a lack of oxygen in the body. As the disease progresses, shortness of breath accompanies each attack. The patient experiences it even at rest.

Heartbeat disorders. It becomes more frequent, and in this case the blows are felt more strongly. There may also be interruptions at some points. The heartbeat is felt very weakly.

General malaise. The patient experiences, may fall into, quickly gets tired. There is increased sweating and nausea, leading to vomiting.

In the old days it was called “angina pectoris”. This phrase is not accidental, because angina pectoris is not pain, but severe squeezing and burning in the chest and esophagus. May be felt in the form of pain in the shoulder, arm or wrist, but such cases are less common. Angina pectoris can easily be confused with heartburn. It is not surprising that some people try to cope with it and use soda to do it. In cardiology, angina is considered the most striking symptom, indicating the presence of ischemic heart disease and helping to prevent myocardial infarction. It is much worse when the disease occurs without external manifestations. The asymptomatic form is fatal in most cases.

During a heart attack, the lumen of the arteries is completely blocked by plaques. The pain increases gradually and after half an hour becomes unbearable. The discomfort may not go away for several hours. In the chronic form of coronary heart disease, the lumen of the vessel is not completely blocked, and the attacks of pain are less prolonged.

Psychological symptoms. During a heart attack, the patient may experience inexplicable fear and anxiety.

The main reasons that can cause cardiac ischemia are as follows:

Atherosclerosis. The myocardium is surrounded by two main arteries, through which blood flows to the heart. They are called coronary and branch into many small vessels. If the lumen of at least one of them is partially or completely closed, certain parts of the heart muscle do not receive the necessary nutrients, and most importantly, oxygen. There are no more arteries supplying the heart with blood, so its work is disrupted and coronary artery disease develops.

Arterial blockage occurs due to a condition that affects the arteries. It involves the formation of cholesterol plaques in the arteries that prevent blood from moving. Performing active movements with a lack of oxygen in the heart muscle is accompanied by pain.

At this stage, coronary disease is expressed in the form of angina pectoris. Gradually, myocardial metabolism worsens, pain intensifies, becomes longer lasting and appears at rest. Heart failure develops, the patient suffers from shortness of breath. If the lumen of a coronary artery suddenly becomes blocked as a result of plaque rupture, blood stops flowing to the heart and a heart attack occurs. As a result, death is possible. The patient's condition after a heart attack and its consequences largely depend on the blockage of the artery. The larger the affected vessel, the worse the prognosis.

Poor nutrition. The cause of the formation of plaques on the walls of blood vessels is excess cholesterol in the body, which comes from foods. In general, this substance is necessary, as it is used to create cell membranes and produce a number of hormones. It is deposited on the walls of blood vessels under the influence of stressful situations.

Emotional stress causes the production of a special substance. This, in turn, promotes the sedimentation of cholesterol in the arteries. A properly formulated diet can reduce its amount in the body. It is worth limiting the consumption of foods that contain saturated fats: butter, sausage, fatty cheeses and meats. It is recommended to give preference to fats contained in fish, nuts, and corn. Quickly digestible and high-calorie foods contribute to the development of cardiac ischemia.

Bad habits. Alcohol abuse and smoking affect the functioning of the heart muscle. Cigarette smoke contains a large number of chemicals, including carbon monoxide, which impedes the transport of oxygen, and nicotine, which increases blood pressure. In addition, smoking affects the formation of blood clots and the development of atherosclerosis.

Sedentary lifestyle or excessive exercise. Uneven physical activity creates additional stress on the heart. The cause of ischemia can be both physical inactivity and physical activity that exceeds the body’s capabilities. It is recommended to exercise regularly, individually determining the intensity, duration, and frequency of training.

Obesity. Numerous studies have revealed a direct relationship between excess weight and mortality from cardiovascular diseases. Therefore, it is one of the factors contributing to the development of ischemia.

Diabetes. The risk of developing coronary heart disease is high for patients with type I and type II diabetes mellitus. They need to normalize carbohydrate metabolism to reduce risks.

Psychosocial reasons. There is an opinion that people with higher social status and education are less susceptible to coronary disease.

Diagnosis of coronary artery disease is carried out primarily on the basis of the patient’s sensations. Most often they complain of burning and pain in the chest, shortness of breath, increased sweating, and swelling, which is a clear sign of heart failure. The patient experiences weakness, heartbeat and rhythm disturbances. It is mandatory to perform electrocardiography if ischemia is suspected. Echocardiography is a research method that allows you to assess the condition of the myocardium, determine muscle contractile activity and blood flow. Blood tests are performed. Biochemical changes can reveal coronary heart disease. Carrying out functional tests involves physical activity on the body, for example, walking up the stairs or doing exercises on a machine. In this way, heart pathologies can be detected in the early stages.

To treat ischemia, the following groups of drugs are used in combination: antiplatelet agents, adrenergic blockers, fibrates and statins. Specific remedies are selected by the doctor depending on the form of the disease. Antiplatelet agents improve blood flow; with the help of adrenergic blockers, it is possible to reduce the frequency of contractions of the heart muscle and reduce oxygen consumption. The action of fibrates and statins is aimed at atherosclerotic plaques. The drugs reduce the rate of their appearance and prevent new formations on the walls of blood vessels.

The fight against angina is carried out with the help of nitrates. Natural lipid-lowering drugs are also widely used for the treatment of coronary disease. Anticoagulants influence the formation of blood clots, and diuretics help remove excess fluid from the body.

Since plaques in the vessels cause their narrowing, it is possible to artificially increase the lumen in the coronary arteries. For this purpose, stenting and balloon angioplasty are performed. During these bloodless surgical interventions, the lumen in the vessels expands and blood flow is normalized. These methods have replaced traditional bypass surgery, which today is performed only for some forms of coronary artery disease. During this operation, the coronary arteries are connected to other vessels below the site of the disturbance in the blood flow in them.

In addition to drug treatment and general therapy, the patient needs moderate physical activity. Depending on the form of ischemia, a set of exercises is developed by the doctor. After all, excessive physical activity increases the oxygen demand of the heart muscle and has a negative impact on the development of the disease.

If you have an unexpected attack while walking or playing sports, you should stop and rest, take a sedative and go out into the fresh air. Then you should take a nitroglycerin tablet.

This drug takes effect within 5 minutes. If the pain does not go away, you need to take 2 more tablets. The ineffectiveness of nitroglycerin indicates serious problems, so if there is no improvement in your condition, you should urgently go to the hospital. Prevention of coronary heart disease involves avoiding alcohol consumption, smoking, proper balanced nutrition and regular exercise. It is necessary to monitor and control your weight. The presence of positive emotions and the absence of stress is important.

The basic principles of the diet for ischemia are as follows:

Patients with coronary artery disease will have to minimize salt, sugar, candies and sweets, confectionery, that is, all sources of simple carbohydrates, fatty meat, caviar, spicy and salty foods, chocolate, coffee and cocoa in their diet.

The most important thing is to limit the consumption of foods containing large amounts of cholesterol and fat. You need to eat little, but often.

You should definitely eat foods that contain ascorbic acid, A, B, C, potassium, and calcium.

Vegetable oil used for cooking should be replaced with corn and olive oil. It is much healthier, and also contains fatty acids that have a positive effect on blood circulation.

The diet should be dominated by dairy products, with the exception of butter, cereals, seafood, vegetable soups, low-fat sea fish, for example, cod, egg white omelet, turkey, chicken.

• It is recommended to steam the dishes. In addition, products can be boiled or stewed.

Below is the usual menu for 7 days for patients with cardiac ischemia:

Monday

Breakfast – a slice of whole grain bread, a glass of weak tea without sugar

Lunch – vegetable salad, a piece of boiled skinless chicken, rice, a glass of fruit juice

Dinner – cottage cheese casserole without sugar, a glass of kefir

Tuesday

Breakfast – omelet with several proteins, apple, tea

Lunch – baked potatoes, steamed cod, a slice of rye bread, tea

Dinner – vegetable stew, unsweetened yogurt

Wednesday

Breakfast – oatmeal, fruit juice

Second breakfast – cottage cheese with fruit

Lunch – vegetable salad dressed with olive oil, baked turkey, tea

Dinner – milk soup, tea

Thursday

Breakfast – boiled egg, a slice of whole grain bread, natural yogurt

Second breakfast – apple

Lunch – baked chicken, buckwheat, tea

Dinner – vegetable soup, a glass of kefir

Friday

Breakfast – oatmeal, apple, juice

Second breakfast – a glass of kefir

Lunch – soaked herring, baked, tea

Dinner – vegetable salad dressed with olive oil, a glass of milk

Saturday

Breakfast – cottage cheese casserole with fruit, tea

Second breakfast – natural yogurt

Lunch – boiled sea bass, vegetable salad, glass of milk

Cardiac ischemia or IHD - one of the most common and serious cardiac ailments, characterized by unpredictability and severity of manifestations. The victims of this disease most often are men of active age - 45 years and older.

Disability or sudden death is a very likely outcome with IHD. In our country alone, about 700 thousand deaths caused by various forms of ischemia are recorded annually. Globally, the mortality rate from this disease is almost 70%. That's why regular monitoring is so important!

Blood test for ischemia

Tests for cardiac ischemia

Diagnostics of ischemic heart disease in "MedicCity"

The development of coronary artery disease is provoked by an imbalance between the myocardial need for blood supply and the actual coronary blood flow.

The main reason for insufficient blood supply and oxygen starvation of the heart muscle is narrowing of the coronary arteries due to (atherosclerotic plaques in the lumen of blood vessels), atherothrombosis and (or) spasm.

The pathological process can affect either one or several arteries at once (multivascular lesion). Significant narrowing of the coronary arteries impedes the normal delivery of blood to the myocardial fibers and causes pain in the heart.

Without proper treatment and medical supervision, coronary ischemic heart disease, caused by a lack of oxygen and nutrients, can lead to cardiac arrest and sudden cardiac death.

Factors contributing to the development of ischemic heart disease

The main causes of the development of coronary heart disease can be identified:

• (increases the likelihood of developing ischemia by 2-6 times);
• smoking (in tobacco addicts, the risk of developing coronary heart disease is 1.5-6 times higher than in non-smokers);
• disturbance of lipid and lipoprotein metabolism (promotes the development and increases the risk of ischemia by 2-5 times);
• physical inactivity and obesity (obese, inactive people get sick at least 3 times more often than thin and athletic people);
• disorders of carbohydrate metabolism (with diabetes of both types, the threat of coronary heart disease increases by 2-4 times).

Risk factors also include family history, being of the stronger sex, and old age. When two or more of the listed positions are combined, the risk of developing IHD increases significantly.

ECG for cardiac ischemia

ABPM in the diagnosis of ischemia

ECHO-CG for ischemic heart disease

Detection of myocardial ischemia

Symptoms of coronary heart disease can be either pronounced or subtle.

Among the most characteristic symptoms of IHD are the following:

• Pressing pain and burning behind the sternum and in the heart area during physical activity;
• shortness of breath on exertion.

But sometimes IHD does not reveal itself until myocardial infarction! In this case, the classic symptoms of coronary heart disease may be noticed too late.

Classification of coronary heart disease

Depending on the symptoms, the following main forms of the disease are distinguished:

Coronary death . Symptoms develop rapidly: loss of consciousness, pupils are dilated and do not respond to light. No pulse, no breathing.

Post-infarction cardiosclerosis . Among the characteristic signs: heart rhythm disturbances, acute manifestations (attack of suffocation - “cardiac asthma”, pulmonary edema) and chronic (swelling of the legs, shortness of breath). The patient complains of a feeling of lack of air, shortness of breath, and swelling of his legs and feet.

Acute coronary syndrome. New-onset angina, progressive angina, myocardial infarction, etc.

Myocardial infarction . Often severe pressing and burning pain behind the sternum, radiating to the jaw, left shoulder blade and arm. Lasts up to half an hour or more, does not go away when taking nitroglycerin under the tongue. The patient also develops cold sweats, blood pressure decreases, weakness, vomiting and fear of death may appear.

Angina pectoris . A person complains of chest pain - squeezing, squeezing, burning behind the sternum during physical activity and sometimes at rest. Possible symptoms of angina include pain in the neck, left shoulder blade, lower jaw or left arm. The pain is usually short-lived.

Angina is one of the most striking manifestations of coronary heart disease. Self-treatment of angina pectoris with folk remedies is unacceptable! Only a doctor, based on his professional experience and diagnostic techniques, can draw conclusions about a person’s condition and the necessary treatment measures!

Ultrasound of the heart for angina pectoris

Ultrasound of the heart in "MedicCity"

Blood tests for ischemic heart disease

If angina pectoris occurs for the first time, if angina attacks begin to occur more often, last longer and manifest themselves more strongly, we are talking about acute coronary syndrome and a high risk of developing myocardial infarction. Such patients should be urgently hospitalized by ambulance to a hospital, where coronary angiography will be performed on an emergency basis and blood flow in the arteries of the heart will be restored, which will avoid the occurrence of myocardial infarction and, as a result, disability.

Silent myocardial ischemia

IHD may not be accompanied by pain. This ischemia is called silent ischemia.

The manifestation of the disease in the case of silent myocardial ischemia is often immediate or sudden coronary death. Therefore, it is very important to be regularly examined by a cardiologist, especially for people at risk (diabetics, hypertension, smokers, obese people, the elderly, etc.).

Such hidden ischemia can be detected using some instrumental techniques, for example, treadmill). It is during a stress test that changes specific to IHD are especially pronounced.

Diagnosis of coronary heart disease

The success of preventive and therapeutic measures depends on the timely detection of the disease and correct diagnosis.

Of course, the initial stage of diagnosing IHD is the collection and analysis of the patient’s complaints. This is followed by an examination, during which the cardiologist measures the patient’s blood pressure, visually assesses his condition (degree of swelling, skin tone, sweating, behavioral characteristics, etc.), listens to his heart with a stethoscope for murmurs, rhythm disturbances, etc.

• clinical and biochemical blood tests;
• blood test for markers of myocardial infarction;
• coronary angiography (x-ray contrast examination of the coronary arteries).

Ultrasound of the heart for ischemic heart disease

Diagnostics of ischemic heart disease in "MedicCity"

ABPM in IHD

Treatment of coronary heart disease. Prevention

The success of treating coronary heart disease depends on many factors. Thus, a combination of ischemia with and can significantly aggravate the situation. Whereas the patient’s commitment to a healthy lifestyle and focus on recovery can be a huge help to the doctor and his chosen treatment regimen.

The treatment strategy for coronary artery disease for each individual patient is individual and is determined by the attending physician based on the results of studies and tests. However, we can list the main types of treatment for coronary heart disease used in modern cardiology.

As a rule, patients with coronary artery disease are prescribed:

1. Non-drug therapy , which includes the maximum possible elimination of the threats of coronary artery disease (detection and treatment of concomitant diseases, diet, adherence to work and rest, weight loss, blood pressure control, feasible physical activity, lifestyle changes).

2. Pharmacotherapy (depending on the form of ischemia, the following may be prescribed: aspirin, nitroglycerin, nitrates, calcium antagonists, statins and/or other cholesterol-lowering medications, beta-blockers, angiotensin-converting enzyme inhibitors, trimetazidine, etc.).

3. Surgery . The most common operations for coronary artery disease today are endovascular techniques (stenting of the coronary vessels of the heart and angioplasty), as well as myocardial revascularization (coronary artery bypass grafting).

During operations of the first type, a catheter is inserted into the artery, through which a super-thin conductor is passed with a deflated air balloon and a folded stent - a tube made of the finest medical wire. The balloon is inflated as soon as it reaches the point of narrowing of the lumen - this is necessary to expand the walls of the artery, then the stent is straightened. Next, the balloon is deflated and removed along with the catheter, and the expanded stent remains in the artery, preventing its re-narrowing and ensuring normal blood flow. Coronary artery bypass grafting is a method in which the surgeon bypasses blocked coronary vessels using a graft - a vein taken from the patient's arm or leg. The operation is performed for very serious reasons, since it is performed on an open heart.

As for preventing the disease, the most effective prevention of coronary heart disease, as well as most CVDs, are blood pressure control, a healthy diet, maintaining physical fitness, and quitting tobacco.

Diagnostics and treatment at MedicCity is the right choice for every person who cares about their health! Our team knows how to help you maintain good health for many years! We use equipment from leading manufacturers and carry out all necessary types of diagnostics and other organs and systems with high quality.