Angina pectoris clinical guidelines. Clinical guidelines: Stable coronary heart disease Coronary artery disease clinical guidelines

28.06.2020

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

Features of the therapeutic effect in hypertension

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

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

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

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

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

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

Risk factors for hypertension

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

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

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

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

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

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

Emergency care for hypertensive crisis

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

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

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

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

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

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

A hypertensive crisis can happen for one of two reasons:

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

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

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

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

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

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

Side effects of emergency pills for hypertensive crisis

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

If such sensations arose for the first time - urgently take 1 tablet of nitroglycerin or nitrosorbide under the tongue, 1 tablet of aspirin and call an ambulance!
If within 5-10 minutes after taking 1 tablet of nitroglycerin under the tongue the pain does not go away, take the same dose again. A maximum of three nitroglycerin tablets can be used consecutively. If after this pain, burning sensation, pressure and discomfort behind the sternum persist, you need to urgently call an ambulance!

Complications of a hypertensive crisis: angina pectoris and heart attack
Aortic aneurysm - a complication of hypertensive crisis
When hypertension requires urgent hospitalization

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

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

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

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

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

Symptoms

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

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

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

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

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

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

Etiology (causes of occurrence)

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

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

Course of the disease and prognosis

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

Treatment

To eliminate angina attacks are used:

Conservative methods of treatment, including medicinal (drug) and not drug therapy;
Surgery.

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

Medications

Result to be achieved

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

Non-drug treatments include:

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

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

Classification of angina pectoris

The following classification of the disease is accepted:

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

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

Stable exertional angina

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

I functional class

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

Most people suffering from angina pectoris of this FC consider themselves healthy people and do not resort to medical assistance. However, coronary angiography shows that they have single vessel lesions. medium degree. Carrying out a bicycle ergometric test also gives a positive result.

II functional class

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

III functional class

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

IV functional class

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

Unstable angina

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

The nature and severity of the occurrence:
1. Class I initial stage chronic angina. The first signs of the onset of the disease were noted shortly before going to the doctor. In this case, the exacerbation of coronary artery disease is less than two months.
2. Class II. Subacute flow. Pain syndromes were noted during the entire month preceding the date of the visit to the doctor. But for the last two days they have been absent.
3. Class III. The current is sharp. Attacks of stenocardia were observed at rest during the last two days.
Occurrence conditions:
1. Group A. Unstable, secondary angina pectoris. The cause of its development are factors provoking coronary artery disease (hypotension, tachyarrhythmia, uncontrolled hypertension, infectious diseases accompanied by fever, anemia, etc.)
2. Group B. Unstable, primary angina. It develops in the absence of factors that increase the course of coronary artery disease.
3. Group C. Early postinfarction angina pectoris. Occurs in the coming weeks, after suffering an acute myocardial infarction.
Against the background of ongoing therapeutic treatment:
1. It develops with a minimum of medical procedures (or not carrying them out).
2. With a course of medication.
3. Development continues with intensive treatment.

rest angina

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

Resting angina is a more severe course of exertional angina. Most often, the onset of an attack is preceded by a psycho-emotional load, elevating HELL.

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

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

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

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

Prinzmetal's angina

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

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

The nature of pain in angina pectoris

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

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

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

At-risk groups

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

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

Emergency care for angina pectoris

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

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

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

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

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

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

Today fast-acting nitrates are available in various forms ah, which act instantly and are much more effective than tablets. These are aerosols called Nitro poppy, Isotket, Nitrospray.

The way to use them is as follows:

Shake the bottle
Point the spraying device at oral cavity sick,
Make him hold his breath, inject one dose of aerosol, trying to get under the tongue.

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

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

Diagnostics

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

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

Video: Diagnosis of elusive angina

Drugs for the treatment of angina pectoris

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

Video: Expert opinion on the treatment of angina pectoris with an analysis of a clinical case

Alternative medicine in the treatment of angina pectoris

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

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

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

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

Prevention of angina pectoris

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

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

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

Video: Angina - how to protect your heart?

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

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

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

Main cause of coronary artery disease

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

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

Video: IHD and atherosclerosis

When do we take risks?

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

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

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

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

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

Video: the occurrence and course of ischemia

Does everything depend on us?

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

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

Not all of us can boast excellent health, consistent diet and regular exercise. Large workloads, stress, constant haste, the inability to eat balanced and regular are frequent companions of our daily rhythm of life.

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

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

Types and forms of coronary heart disease

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

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

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

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

Manifestations of myocardial ischemia

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

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

Angina pectoris and its types

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

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

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

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

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

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

Myocardial infarction, what does this concept mean?

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

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

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

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

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

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

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

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

How to recognize a heart attack?

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

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

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

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

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

Video: how the heart works, myocardial infarction

Consequences and complications of coronary artery disease

Postinfarction cardiosclerosis

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

Chronic heart failure

Chronic heart failure is accompanied by the occurrence of edema, shortness of breath, a decrease in exercise tolerance, as well as the appearance of irreversible changes in internal organs which can lead to the death of the patient.

Acute heart failure

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

Cardiogenic shock

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

Arrhythmia

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

Methods for diagnosing coronary heart disease

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

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

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

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

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

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

Methods of treatment of various forms of myocardial ischemia

There are currently many various ways treatment of coronary heart disease, which can not only prolong the life of the patient, but also significantly improve its quality. These can be conservative (use of drugs, exercise therapy) and surgical methods(operations restoring the patency of the coronary vessels).

Proper nutrition

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

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

Medical therapy

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

For all acute forms IHD needs fast and qualified help with the use of effective painkillers, thrombolytics, it may be necessary to administer plasma-substituting drugs (with the development cardiogenic shock) or performing defibrillation.

Operation

Surgical treatment of cardiac ischemia is reduced to:

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

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

Video: lecture by a specialist on the treatment of ischemia

After discharge from the hospital

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

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

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

Tests for hypertension: screening for hypertension

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

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

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

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

myocardial infarction;
stroke
lethal outcome.

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

Causes and types of hypertension

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

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

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

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

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

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

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

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

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

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

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

What tests need to be done

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

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

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

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

structural anomalies;
valve changes;
developmental defects.

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

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

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

In hypertension, carry out laboratory research and analyses:

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

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

Features of the ECG

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

The main indicators to evaluate the ECG:

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

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

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

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

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

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

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

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

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

For all high value data should be evaluated with the obligatory consideration of all clinical indicators, since different pathological processes can have many similar changes.

How to prepare for the procedure

Despite the assertion that there is no need to prepare for an electrocardiography, experienced doctors strongly recommend that you take the procedure seriously. The essence of the manipulation is to assess the work of the heart muscle under normal conditions. For this reason, it is extremely important before the cardiogram:

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

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

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

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

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

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

kidneys;
liver;
hearts;
brain.

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

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

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

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

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

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

Prevention

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

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

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

It is important to periodically:

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

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

Medical treatment of angina pectoris

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

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

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

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

Features of prescribing drugs

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

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

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

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

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

Nitrates for the treatment of angina pectoris

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

List of nitrates commonly prescribed by a doctor:

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

β-blockers for the treatment of angina pectoris

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

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

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

Calcium channel blockers for the treatment of angina pectoris

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

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

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

Antiplatelet agents for the treatment of angina pectoris

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

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

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

Statins for the treatment of angina pectoris

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

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

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

Dosage of drugs

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

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

Without what medical treatment is impossible?

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

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

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

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

Lupanov V.P.

December 2012 G. published in the Journal of the American College of Cardiology new practical recommendations By diagnostics And treatment sick stable ischemic sickness hearts(CHS).

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

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

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

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

Diet, weight loss and regular physical activity;

If the patient is a smoker - stop smoking;

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

Taking statins in moderate doses;

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

If the patient is diabetic - proper control glycemia .

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

4.4.1. Modification of risk factors

4.4.1.1. Effect on blood lipids

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

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

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

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

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

additional drug therapy to prevent

myocardial infarction and death

in patients stable ischemic heart disease

4.4.2.1. Antiplatelet therapy

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

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

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

4.4.2.2. Therapy with b-blockers

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

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

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

4.4.2.3. ACE inhibitors and blockers

angiotensin receptors

(renin-angiotensin-aldosterone blockers)

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

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

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

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

4.4.2.4. Influenza vaccination

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

Class III. Benefit not proven.

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

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

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

4.4.3. Medical therapy

to relieve symptoms

4.4.3.1. Therapy with anti-ischemic

drugs

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

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

3. Calcium channel blockers or long-acting nitrates in combination with β-blockers should be given to relieve symptoms when initial therapy with β-blockers is not effective in patients with stable CAD (Evidence B).

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

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

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

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

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

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

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

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

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

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

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

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

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

Conclusion

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

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

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

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

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

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

Literature

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

18. Aronov D.M. Lupanov V.P. atherosclerosis and coronary disease hearts. Second edition, revised. - M. Triada X, 2009. - 248 p.

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

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

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

Dear colleagues!

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

President of the All-Russian Scientific Society of Cardiology,

Academician of RAMS

R. G. Oganov

Introduction

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

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

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

List of abbreviations and conventions

A - angiotensin

AV block - atrioventricular block

AG - arterial hypertension

BP - blood pressure

AIR - agonists of I 1 -imidazoline receptors

AK - calcium antagonists

ACS - associated clinical conditions

ACTH - adrenocorticotropic hormone

AO - abdominal obesity

ARP - renin activity in blood plasma

BA - bronchial asthma

BAB - beta-blockers

ACE inhibitors - angiotensin-converting inhibitors

enzyme

IHD - ischemic heart disease

MI - myocardial infarction

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

BMI - body mass index

TIA - transient ischemic attack

Ultrasound - ultrasonography

FA - physical activity

FK - functional class

FN - physical activity

RF - risk factors

COPD - chronic obstructive pulmonary disease

CNS - central nervous system

ECG - electrocardiogram

EchoCG - echocardiography

Definition

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

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

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

Diagnostics

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

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

- exclusion of symptomatic hypertension or identification of its form;

- assessment of overall cardiovascular risk;

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

diagnosis of POM and assessment of their severity.

Diagnosis of hypertension and subsequent examination includes the following steps:

repeated measurements of blood pressure;
collection of anamnesis;
physical examination;

laboratory and instrumental research methods: simpler at the first stage and complex at the second stage of the examination.

Rules for measuring blood pressure

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

The following conditions are important for measuring blood pressure:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The most important diagnostic method for complaints of chest pain is the history taking.
At the diagnostic stage, it is recommended to analyze complaints and take anamnesis in all patients with suspected coronary artery disease.

Comments. The most common complaint in angina pectoris, as the most common form of stable CAD, is chest pain.
It is recommended to ask the patient about the existence of pain in the chest, the nature, frequency of occurrence and circumstances of disappearance.
Recommendation strength level I (Evidence level C).
Comments. Signs of a typical (undoubted) exertional angina:
Pain in the sternum, possibly radiating to the left arm, back or lower jaw, less often to the epigastric region, lasting 2-5 minutes. Pain equivalents are shortness of breath, a feeling of "heaviness", "burning".
The above pain occurs during physical exertion or severe emotional stress.
The above pain quickly disappears after the cessation of physical activity or after taking nitroglycerin.
To confirm the diagnosis of typical (undoubted) angina pectoris, the patient must have all three of the above signs at the same time.
There are atypical variants of localization of pain and irradiation. The main symptom of angina pectoris is a clear dependence of the onset of symptoms on physical activity.
The equivalent of angina pectoris can be shortness of breath (up to suffocation), a feeling of "heat" in the sternum, attacks of arrhythmia during exercise.
The equivalent of physical activity can be a crisis increase in blood pressure (BP) with an increase in the load on the myocardium, as well as a heavy meal.
The diagnosis of atypical angina is made if the patient has any two of the three signs of typical angina listed above.
Signs of non-anginal (non-anginal) chest pain:
Pain is localized alternately to the right and left of the sternum.
The pains are local, "point" character.
After the onset of pain lasts more than 30 minutes (up to several hours or days), it can be constant, “shooting” or “suddenly piercing”.
Pain is not associated with walking or other physical activity, but occurs when tilting and turning the body, in the prone position, with a long stay of the body in an uncomfortable position, with deep breathing at the height of inspiration.
Pain does not change after taking nitroglycerin.
Pain is aggravated by palpation of the sternum and / or chest along the intercostal spaces.
A feature of the pain syndrome in the chest with vasospastic angina is that the pain attack, as a rule, is very strong, localized in a “typical” place - in the sternum. However, often such attacks occur at night and early in the morning, as well as when exposed to cold on open areas of the body.
A feature of the pain syndrome in the chest with microvascular angina pectoris is that anginal pain, in terms of quality and localization corresponding to angina pectoris, but arising some time after exercise, and poorly relieved by nitrates, may be a sign of microvascular angina pectoris.
If during the questioning the syndrome of angina pectoris is detected, it is recommended to determine its functional class, depending on the exercise to be tolerated.
Recommendation strength level I (Evidence level C).
Comments. There are 4 functional classes (FC) of angina according to the classification of the Canadian Society of Cardiology (Table 1).
Table 1. Functional classes of angina pectoris.

Functional class I	Functional class II	Functional class III	Functional class IV
"Latent" angina pectoris. Seizures occur only under extreme stress	Attacks of angina pectoris occur during normal exercise: brisk walking, uphill, stairs (1-2 flights), after a heavy meal, severe stress	Attacks of angina sharply limit physical activity: they occur with a slight load: walking at an average pace< 500 м, при подъеме по лестнице на 1-2 пролета. Изредка приступы возникают в покое	Inability to perform any, even minimal load due to the occurrence of angina pectoris. Seizures occur at rest. Frequent history of myocardial infarction, heart failure

During the collection of anamnesis, it is recommended to clarify the fact of smoking now or in the past.
Recommendation strength level I (Evidence level C).
During the history taking, it is recommended to ask about the cases of CVD from the patient's immediate family (father, mother, siblings).
Recommendation strength level I (Evidence level C).
During the history taking, it is recommended to ask the patient's next of kin (father, mother, siblings) about CVD deaths.
Recommendation strength level I (Evidence level C).
During the history taking, it is recommended to ask about previous cases of seeking medical help and about the results of such requests.
Recommendation strength level I (Evidence level C).
During the collection of anamnesis, it is recommended to clarify whether the patient has previously recorded electrocardiograms, the results of other instrumental studies and conclusions on these studies.
Recommendation strength level I (Evidence level C).
During the history taking, it is recommended to ask the patient about known comorbidities.
Recommendation strength level I (Evidence level C).
During the history taking, it is recommended to ask the patient about all currently taken medications.
Recommendation strength level I (Evidence level C).
During the history taking, it is recommended to ask the patient about all drugs that were previously discontinued due to intolerance or ineffectiveness. Strength of recommendation IIa (Level of evidence C).

2.2 Physical examination.

At the stage of diagnosis, all patients are recommended to conduct a physical examination.
Recommendation strength level I (Evidence level C).
Comments. Usually, the physical examination for uncomplicated stable CAD has little specificity. Sometimes a physical examination can reveal signs of RF: overweight and signs of diabetes mellitus (DM) (scratching, dry and sagging skin, decreased skin sensitivity). Signs of atherosclerosis of the heart valves, aorta, main and peripheral arteries are very important: noise over the projections of the heart, abdominal aorta, carotid, renal and femoral arteries, intermittent claudication, coldness of the feet, weakening of the pulsation of the arteries and atrophy of the muscles of the lower extremities. A significant risk factor for coronary artery disease, detected during physical examination, is arterial hypertension (AH). In addition, you should pay attention to the external symptoms of anemia. In patients with familial forms of hypercholesterolemia (HCS), examination may reveal xanthomas on the hands, elbows, buttocks, knees, and tendons, as well as xanthelasmas on the eyelids. The diagnostic value of physical examination increases when symptoms of coronary artery disease complications are present - primarily signs of heart failure: shortness of breath, wheezing in the lungs, cardiomegaly, cardiac arrhythmia, swelling of the jugular veins, hepatomegaly, swelling of the legs. The detection of signs of heart failure during physical examination usually suggests postinfarction cardiosclerosis and a very high risk of complications, and therefore dictates the need for urgent complex treatment, including with possible myocardial revascularization.
During a physical examination, it is recommended to conduct a general examination, examine the skin of the face, trunk and extremities.
Recommendation strength level I (Evidence level C).
During the physical examination, it is recommended to measure height (m) and weight (kg) and determine the body mass index.
Recommendation strength level I (Evidence level C).
Comments. The body mass index is calculated by the formula - "weight (kg) / height (m) 2".
During a physical examination, it is recommended to auscultate the heart and lungs, palpate the pulse on the radial arteries and the arteries of the dorsal surface of the feet, measure blood pressure according to Korotkov in the patient’s position lying, sitting and standing, calculate the heart rate and pulse rate, auscultate the projection points of the carotid arteries, abdominal aorta, iliac arteries, palpate the abdomen, parasternal points and intercostal spaces.
Recommendation strength level I (Evidence level C).

2.3 Laboratory diagnostics.

Few laboratory tests have independent predictive value in stable CAD. The most important parameter is the lipid profile of the blood. Other laboratory tests of blood and urine can reveal concomitant diseases and syndromes (thyroid dysfunction, diabetes mellitus, heart failure, anemia, erythremia, thrombocytosis, thrombocytopenia), which worsen the prognosis of coronary artery disease and require consideration when selecting drug therapy and, if possible, referring the patient to surgery. treatment.
All patients are advised to have a complete blood count with measurements of hemoglobin, red blood cells and white blood cells.

When clinically warranted, screening for type 2 diabetes is recommended to begin with measurements of glycosylated hemoglobin and fasting blood glucose. If the results are inconclusive, an oral glucose tolerance test is additionally recommended.

All patients are advised to conduct a study of blood creatinine levels with an assessment of kidney function by creatinine clearance.
Recommendation strength level I (level of evidence B).
It is recommended that all patients undergo a fasting blood lipid spectrum study, including an assessment of the level of low-density lipoprotein cholesterol (LDL-C).

Comments. Dyslipoproteinemia - a violation of the ratio of the main classes of lipids in plasma - the leading risk factor for atherosclerosis. Low density and very low density lipoproteins are considered protatherogenic, while high density lipoproteins are an antiatherogenic factor. With a very high content of LDL-C in the blood, IHD develops even in young people. Low HDL cholesterol is an unfavorable prognostic factor. A high level of blood triglycerides is considered a significant predictor of CVD.
When clinically warranted, thyroid function screening is recommended to detect thyroid disease.

In patients with suspected heart failure, it is recommended to study the level of the N-terminal fragment of the brain natriuretic peptide in the blood.
Strength of recommendation IIa (level of evidence C);
In case of clinical instability of the condition or if ACS is suspected, repeated measurement of blood troponin levels by a highly or ultra-highly sensitive method is recommended to rule out myocardial necrosis.
Recommendation strength level I (Level of Evidence A);
In patients complaining of symptoms of myopathy while taking statins, it is recommended to study the activity of blood creatine kinase.
Recommendation strength level I (level of evidence C);
In repeated studies in all patients with a diagnosis of stable coronary artery disease, it is recommended to conduct an annual monitoring of the lipid spectrum, creatinine and glucose metabolism.
Recommendation strength level I (Evidence level C).

2.4 Instrumental diagnostics.

Electrocardiographic study.
All patients with suspected coronary artery disease, when contacting a doctor, are advised to perform electrocardiography (ECG) at rest and decipher the electrocardiogram.
Recommendation strength level I (level of evidence C) ;
Resting ECG is recommended for all patients during or immediately after an episode of chest pain suggestive of unstable CAD.
If vasospastic angina is suspected, an ECG recording during an attack of chest pain is recommended.
Recommendation strength level I (Evidence level C);
Comments. In uncomplicated stable CAD outside exercise, specific ECG signs of myocardial ischemia are usually absent. The only specific sign of IHD on the resting ECG is large-focal cicatricial changes in the myocardium after myocardial infarction. Isolated changes in the T wave, as a rule, are not very specific and require comparison with the clinic of the disease and data from other studies. Registration of an ECG during a pain attack in the chest is of much greater importance. If there are no ECG changes during pain, the probability of coronary artery disease in such patients is low, although it is not completely excluded. The appearance of any ECG changes during a pain attack or immediately after it significantly increases the likelihood of coronary artery disease. Ischemic ECG changes in several leads at once are an unfavorable prognostic sign. In patients with initially altered ECG due to postinfarction cardiosclerosis, ECG dynamics during an attack of even typical angina may be absent, be of little specificity, or false (decrease in amplitude and reversion of initially negative T waves). It should be remembered that against the background of intraventricular blockades, ECG registration during a pain attack is also uninformative. In such cases, the doctor decides on the nature of the attack and the tactics of treatment according to the accompanying clinical symptoms.
echocardiographic study.
A resting transthoracic echocardiogram (EchoCG) is recommended in all patients with suspected stable CAD and with previously proven stable CAD.
Recommendation strength level I (level of evidence B).
Comments. The main purpose of echocardiography at rest is the differential diagnosis of angina pectoris with non-coronary chest pain in aortic valve defects, pericarditis, ascending aortic aneurysms, hypertrophic cardiomyopathy, mitral valve prolapse and other diseases. In addition, echocardiography is the main way to detect and stratify myocardial hypertrophy, local and general left ventricular dysfunction.
A resting transthoracic echocardiogram (EchoCG) is done to:
ruling out other causes of chest pain;
detection of local disorders of the mobility of the walls of the left ventricle of the heart;
measurement of the left ventricular ejection fraction (LVEF) and subsequent CV risk stratification;
assessment of diastolic function of the left ventricle.
Ultrasound examination of the carotid arteries.
Ultrasound examination of the carotid arteries in stable CAD is recommended to detect atherosclerosis of the carotid arteries as an additional risk factor for CVE.

Comments. The detection of multiple hemodynamically significant stenoses in the carotid arteries forces us to reclassify the risk of CVE as high, even with moderate clinical symptoms.
X-ray examination in stable coronary artery disease.
At the diagnostic stage, a chest x-ray is recommended in patients with atypical symptoms of CAD or to rule out lung disease.
Recommendation strength level I (Evidence level C).
At the diagnostic stage, at follow-up, a chest x-ray is recommended if HF is suspected.
Strength of recommendation IIa (Level of evidence C).
A comment. Chest x-ray is most informative in patients with postinfarction cardiosclerosis, heart disease, pericarditis, and other causes of concomitant HF, as well as in suspected aneurysms of the ascending aortic arch. In such patients, on radiographs, it is possible to assess an increase in the heart and aortic arch, the presence and severity of intrapulmonary hemodynamic disorders (venous stasis, pulmonary arterial hypertension). In atypical chest pain, an X-ray examination can be useful for identifying diseases of the musculoskeletal system during the differential diagnosis.
ECG monitoring.
ECG monitoring is recommended in patients with proven stable CAD and suspected concomitant arrhythmias.
Recommendation strength level I (Evidence level C).
ECG monitoring is recommended at the diagnostic stage in patients with suspected vasospastic angina.
Strength of recommendation IIa (Level of evidence C).
ECG monitoring is recommended at the diagnostic stage if it is impossible to perform stress tests due to concomitant diseases (diseases of the musculoskeletal system, intermittent claudication, a tendency to a pronounced increase in blood pressure during dynamic physical exertion, detraining, respiratory failure).
Strength of recommendation IIa (Level of evidence C).
A comment. The method allows to determine the frequency of occurrence and duration of painful and painless myocardial ischemia. Sensitivity of ECG monitoring in the diagnosis of coronary artery disease: 44-81%, specificity: 61-85%. This diagnostic method is less informative for detecting transient myocardial ischemia than exercise tests. Prognostically unfavorable findings during ECG monitoring: 1) long total duration of myocardial ischemia; 2) episodes of ventricular arrhythmias during myocardial ischemia; 3) myocardial ischemia with low heart rate (< 70 уд. /мин). Выявление суммарной продолжительности ишемии миокарда 60 мин в сутки служит веским основанием для направления пациента на коронароангиографию (КАГ) и последующую реваскуляризацию миокарда, поскольку говорит о тяжелом поражении КА .
Evaluation of data from the primary survey and pre-test probability of coronary artery disease.
It is recommended that when examining individuals without a previously established diagnosis of coronary artery disease, it is recommended to assess the pre-test probability (PTP) of this diagnosis based on data obtained during the collection of anamnesis, physical and laboratory examinations, ECG at rest, echocardiography and performed according to the indications of chest x-ray, ultrasound examination of the carotid arteries and ambulatory ECG monitoring.
Recommendation strength level I (Evidence level C).
Comments. After the initial studies, the doctor builds a plan for further examination and treatment of the patient, based on the primary data obtained and the PTT of the diagnosis of stable coronary artery disease (Table 2).
Table 2. Pretest probability of diagnosis of stable coronary artery disease depending on the nature of chest pain.

Age, years	Typical angina		Atypical angina		Non-coronary pain
	men	women	men	women	men	women
30-39	59%	28%	29%	10%	18%	5%
40-49	69%	37%	38%	14%	25%	8%
50-59	77%	47%	49%	20%	34%	12%
60-69	84%	58%	59%	28%	44%	17%
70-79	89%	68%	69%	37%	54%	24%
80	93%	76%	78%	47%	65%	32%

It is recommended that in patients with PTV diagnosed with coronary heart disease 65%, further studies to confirm the diagnosis should not be carried out, but proceed to the stratification of the risk of CVD and the appointment of treatment.
Recommendation strength level I (Evidence level C).
Recommended. Patients with PTV diagnosed with coronary artery disease< 15% направить на обследование для выявления функционального заболевание сердца или некардиальных причин клинических симптомов.
Recommendation strength level I (Evidence level C).
It is recommended that patients with an intermediate PTT diagnosis of CAD (15-65%) be referred for additional non-invasive exercise and imaging diagnostic studies.
Recommendation strength level I (Evidence level C).
ECG registration during exercise tests.
Stress ECG with exercise is recommended as an initial method for establishing the diagnosis of angina syndrome against the background of intermediate PTT detection of coronary artery disease (15-65%), not taking anti-ischemic drugs.
Recommendation strength level I (Level of evidence B).
Comments. An exercise stress ECG is not performed when the patient is unable to exercise or if the underlying changes in the ECG make evaluation impossible.
An exercise stress ECG is recommended in patients with established CAD and on treatment to assess its effect on symptoms and myocardial ischemia.
Strength of Recommendation IIa (Level of Evidence C) ;
Stress ECG with exercise is not recommended in patients receiving cardiac glycosides, as well as with ST segment depression on the ECG at rest of 0.1 mV.
Level of recommendation III (Level of evidence C).
A comment. Usually the stress test is a bicycle ergometry or treadmill test. The sensitivity of stress ECG with exercise in the diagnosis of coronary artery disease is 40-50%, the specificity is 85-90%. The walking test (treadmill test) is more physiological and is more often used to verify the functional class of patients with coronary artery disease. Bicycle ergometry is more informative in detecting coronary artery disease in unclear cases, but at the same time it requires the patient to have at least basic cycling skills, it is more difficult to perform in elderly patients and with concomitant obesity. The prevalence of transesophageal atrial electrical stimulation in the daily diagnosis of coronary artery disease is lower, although this method is comparable in informational content to bicycle ergometry (VEM) and the treadmill test. The method is performed according to the same indications, but is the means of choice if the patient cannot perform other stress tests due to non-cardiac factors (diseases of the musculoskeletal system, intermittent claudication, a tendency to a pronounced increase in blood pressure during dynamic physical exertion, detraining, respiratory failure). .
Stress methods for visualization of myocardial perfusion.
Stress methods of myocardial perfusion imaging include:
Stress echocardiography with exercise.
Stress echocardiography with pharmacological loading (dobutamine or vasodilator).
Stress echocardiography with a vasodilator.
Perfusion myocardial scintigraphy with physical activity.
Stress echocardiography is one of the most popular and highly informative methods for non-invasive diagnosis of coronary artery disease. The method is based on visual detection of local LV dysfunction, as an equivalent of ischemia, during exercise or a pharmacological test. Stress EchoCG is superior to conventional exercise ECG in terms of diagnostic value, has greater sensitivity (80-85%) and specificity (84-86%) in the diagnosis of coronary artery disease. The method allows not only to verify ischemia conclusively, but also to preliminarily determine symptom-related coronary artery disease by the localization of transient LV dysfunction. With technical feasibility.
Stress echocardiography with exercise is indicated for all patients with proven coronary artery disease for verification, symptom-related coronary artery disease, as well as in doubtful results of a routine exercise test during the initial diagnosis.
Strength of recommendation IIa (Level of evidence C).
If microvascular angina is suspected, stress echocardiography with exercise or dobutamine is recommended to verify local hypokinesis of the LV wall, which occurs simultaneously with angina and ECG changes.
Strength of recommendation IIa (Level of evidence C);
If microvascular angina is suspected, echocardiography with Doppler examination of the left coronary artery with measurement of diastolic coronary blood flow after intravenous administration of adenosine is recommended to study the coronary blood flow reserve.
Strength of recommendation IIb (Level of Evidence C).
A comment. Myocardial perfusion scintigraphy (single photon emission computed tomography and positron emission tomography) is a sensitive and highly specific imaging method with high prognostic value. The combination of scintigraphy with physical activity or pharmacological tests (dosed intravenous administration of dobutamine, dipyridamole) greatly increases the value of the results obtained. The method of positron emission tomography makes it possible to estimate the minute blood flow per unit mass of the myocardium and is especially informative in the diagnosis of microvascular angina pectoris.
Conducting a scintigraphic study of myocardial perfusion in combination with physical activity is recommended for stable CAD for verification, symptom-related coronary artery disease and for assessing the prognosis of the disease.
Strength of Recommendation IIa (Level of Evidence C);
A scintigraphic study of myocardial perfusion in combination with a pharmacological test (intravenous administration of dobutamine or dipyridamole) is recommended for stable coronary heart disease for verification, symptom-related coronary artery disease and for assessing the prognosis of the disease if the patient cannot perform standard physical activity (due to detraining, diseases of the musculoskeletal system). apparatus and/or lower extremities, etc.).

Positron emission tomography of myocardial perfusion is recommended in the diagnosis of microvascular angina.
Strength of Recommendation IIb (Level of Evidence C);
Stress imaging is recommended as the initial method for diagnosing stable CAD with a PTT of 66-85% or with an LVEF.< 50% у лиц без типичной стенокардии .
Strength of Recommendation I (Level of Evidence B);
Stress imaging is recommended as an initial diagnostic method if resting ECG features preclude its interpretation during exercise.
Recommendation strength level I (Level of evidence B).
Exercise-assisted imaging is recommended over pharmacological exercise.
Strength of Recommendation I (Level of Evidence C);
Stress imaging is recommended as the preferred method in individuals with symptoms of coronary artery disease who have undergone previous percutaneous coronary intervention (PCI) or coronary bypass surgery (CABG).
Strength of recommendation IIa (Level of evidence B);
Stress imaging is recommended as the preferred method for assessing the functional significance of intermediate stenoses according to CAG.
Strength of Recommendation Level IIa (Level of Evidence B) ;
In patients with stable CAD with a pacemaker, stress echocardiography or single photon emission computed tomography is recommended.

Stress imaging for CV risk stratification is recommended in patients with inconclusive exercise stress ECG results.

CV risk stratification using stress ECG or stress imaging is recommended in patients with stable CAD when there is a significant change in the frequency and severity of symptoms.
Recommendation level I (Level of evidence B).
With concomitant blockade of the left branch of the His bundle, stress echocardiography or single-photon emission computed tomography of the myocardium with a pharmacological load is recommended for stratification according to the risk of CVE.
Strength of recommendation IIa (Level of evidence B).
Invasive studies in stable coronary artery disease.
Invasive coronary angiography (CAG) is traditionally the "gold standard" in the diagnosis of coronary artery disease and in risk stratification of complications.
In cases of proven coronary artery disease, coronary angiography is recommended for CV risk stratification in individuals with severe stable angina (FC III-IV) or with clinical signs of high CV risk, especially when symptoms are difficult to treat.
Recommendation strength level I (Evidence level C).

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

DIAGNOSIS AND TREATMENT

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

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

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

Minsk, 2010


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

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

List of abbreviations and symbols used in recommendations

AH - arterial hypertension

BP - blood pressure

AK - calcium antagonists

CABG - coronary artery bypass grafting

ACE - angiotensin converting enzyme

ASA - acetylsalicylic acid

BB - beta-blockers

SIMI - painless (silent) myocardial ischemia

CVD - disease of the circulatory system

WHO - World Health Organization

BC - sudden death

VEM - bicycle ergometric test

HCM - hypertrophic cardiomyopathy

LVH - left ventricular hypertrophy

HRH - right ventricular hypertrophy

DBP - diastolic blood pressure

DCM - dilated cardiomyopathy

DP - double product

DFT - dosed physical training

IA - atherogenicity index

IHD - ischemic heart disease

ID - isosorbide dinitrate

MI - myocardial infarction

IMN - isosorbide mononitrate

CA - coronary arteries

CAG - coronary angiography

QOL - quality of life

KIAP - cooperative study of antianginal drugs

CABG - coronary artery bypass grafting

Minsk, 2010

HDL - high density lipoproteins

LV - left ventricle

LDL - low density lipoproteins

VLDL - very low density lipoproteins

Lp - lipoprotein

MET - metabolic unit

MSCT - multislice computed tomography

MT - drug therapy

NG - nitroglycerin

IGT - Impaired Glucose Tolerance

FROM / OB - waist / hips

PET - Positron Emission Tomography

RFP - radiopharmaceutical

SBP - systolic blood pressure

DM - diabetes mellitus

CM - daily monitoring

CVD - cardiovascular diseases

CCH - stable exertional angina

TG - triglycerides

EF - ejection fraction

FK - functional class

RF - risk factor

COPD - chronic obstructive pulmonary disease

CS - total cholesterol

TEAS - transesophageal atrial electrical stimulation

HR - heart rate

PTCA - percutaneous coronary artery plasty

ECG - electrocardiography

EchoCG - echocardiography

1. INTRODUCTION

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

IN In 2009, there was an increase in the proportion of mortality from CSD up to 54% (2008 - 52.7%) due to an increase in mortality from chronic coronary artery disease by 1.3% (2008 - 62.5%, 2009 - 63, 8%). In the structure of the primary access to disability of the population of the Republic of Belarus, CSCs in 2009 amounted to 28.1% (in 2008 - 28.3%); mostly patients with coronary artery disease.

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

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

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

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Diagnosis and treatment of stable angina pectoris

		Reliable evidence and/or unanimity of expert opinion
		that the procedure or treatment is appropriate
		that the procedure or treatment is appropriate
		different, useful and effective.
		different, useful and effective.
		Contradictory data and / or divergence of expert opinions
		about the benefits/effectiveness of procedures and treatments

		Dominant evidence and/or expert opinion on the use of
		ze / effectiveness of therapeutic effects.
		Benefits/effectiveness not well established
		evidence and/or expert opinion.
		The available data or the general opinion of experts is evidence
		feel that the treatment is not useful/effective
		feel that the treatment is not useful/effective
		and in some cases can be harmful.
		and in some cases can be harmful.

* Class III use not recommended

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

Levels of Evidence

Results of numerous randomized clinical trials or meta-analysis.

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

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

2. DEFINITION AND CAUSES OF ANGINA

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

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

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

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

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

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

Minsk, 2010

Diagnosis and treatment of stable angina pectoris

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

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

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

3. CLASSIFICATION OF ANGINA

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

And treated with nitroglycerin.

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

I25 Chronic ischemic heart disease

I25.6 Asymptomatic myocardial ischemia

I25.8 Other forms of ischemic heart disease

I20 Angina pectoris [angina pectoris]

I20.1 Angina pectoris with documented spasm

I20.8 Other angina pectoris

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

Classification of stable angina

1. Angina pectoris:

1.1. first-time angina pectoris.

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

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

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

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

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

Canadian Association of Cardiology (L. Campeau, 1976)

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

"Significant limitation of usual physical activity"

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

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

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