Coronary heart disease. Icb code ischemic heart disease Ischemic disease according to Icb 10

Determining the IHD code according to ICD 10 is always a long and laborious process. The disease is located in the class of pathologies of the circulatory system. At its core, IHD is a complex of pathologies that are characterized by a violation of the blood supply to the heart or its individual parts.

Accordingly, ischemia can be acute or chronic. When coding ischemic disease, one should take into account the fact that IHD is often combined with arterial hypertension, and this requires additional clarification of the diagnosis.

In addition, during the statement of a disease in the PICS block according to ICD 10 the duration of the ischemic attack should be considered... At the same time, to conduct statistical accounting of morbidity, the time interval from the onset of ischemia to the patient's admission to the hospital is taken into account. In assessing overall mortality, the time from the onset of an attack to death is estimated.

Encoding features

The code for coronary heart disease in ICD 10 ranges from I20 to I25. This includes the following nosological units:

• I20 - represented by angina pectoris, which is subdivided into stable angina pectoris and an unstable form (stress), as well as unspecified forms of pathology;
• I21 - sharp coronary syndrome or myocardial infarction, which is divided into points depending on the location of the lesion and the depth of necrotic phenomena;
• I22 - repeated infarction, which implies the appearance of signs of myocardial necrosis within 28 days from the development of the previous infarction;
• I23 - complications of an infarction condition (for example, the formation of heart defects, hemopericardium, rupture of some structures);
• I24 - so In the ICD 10 IHD block, other forms of nosology are coded (for example, Dressler's syndrome or coronary thrombosis without signs of heart attack);
• I25 - chronic ischemia of the heart, which is also divided into many points (atherosclerosis, aneurysm, heart attack and other forms).

Coronary artery disease means that, for whatever reason, the heart does not receive enough blood to function properly.

In adults, IHD occurs much more often than in children, which is due to nutritional disorders, bad habits, the accumulation of harmful substances in the body and others. external factors... At the same time, such a pathology coding is needed in order to adequately distribute the basic principles of treatment and diagnosis of a large number of IHD forms.

Ischemic heart disease is the most widespread disease in the world, as it is called, the “disease of the century”. Today, there are no methods that can turn the development of IHD back. A complete cure is also impossible. But with timely and systematic treatment, the development of the disease can be slowed down a little, and life expectancy can also be increased.

What is coronary artery disease?

IHD is an acute or chronic heart dysfunction. It occurs due to insufficient supply of nutrients from the coronary arteries directly to the heart muscle. The main reason is atherosclerosis, plaques are formed, which over time narrow the lumen in the arteries.

Reduced blood flow, upset the balance between: needs and capabilities of the heart to supply it with the nutrition necessary for life.

IHD is included in the ICB code 10. This International classification some diseases 10 revision. ICD-10 includes 21 classes of diseases, including IHD. IHD code: I20-I25.

Classification

Sharp:

• unexpected coronary death of the patient;
• acute heart attack;
• angina pectoris (vasospastic, variant);
• angina pectoris (unstable).

Chronic:

• tense angina (class and rest functionality is indicated);
• postinfarction cardiosclerosis, impaired heart rhythm and its conduction;
• aneurysm;
• painless ischemia.

Symptoms

Mental symptoms:

1. panic, almost animal fear;
2. unexplained apathy;
3. causeless anxiety.

Diagnostics

Purpose of diagnostics:

1. find existing risk factors: not previously diagnosed diabetes, bad cholesterol, kidney disease, etc .;
2. according to the results of diagnostics, the condition of the heart muscle and arteries should be assessed;
3. find the right treatment;
4. understand whether an operation is needed, or you can still carry out conservative treatment.

First, you will need a consultation with a specialist cardiologist. If an operation is indicated, then a cardiac surgeon is needed. With high sugar, the treatment is first carried out by an endocrinologist.

Blood tests are prescribed:

• general;
• blood for sugar;
• general lipid profile;
• urea, creatine (assesses the performance of the kidneys).

Urine tests:

• microalbuminuria (MAU) - for the presence of a protein: called albumin.
• proteinuria - determines the health of the kidneys.

Other diagnostics:

• blood pressure measurement;
• radiography;
• ECG without load;
• Stress ECG;
• determination of the level of harmful cholesterol in the blood;
• Echo KG - ultrasound of the heart;
• coronary angiography.

When diagnosing, it is necessary to take into account the forms of ischemic heart disease, there are five of them:

1. Exertional angina.
2. Vasospastic angina.
3. Myocardial infarction.
4. Postinfarction cardiosclerosis.
5. Heart failure.

Causes

There are two reasons:

1. It is called a disease - "heat". This is when the liver makes cholesterol. This is called the imbalance of the Mkhris-pa regulatory system.
2. This is a disease - "cold" is associated with digestion. With an abnormal slowdown in digestion and a violation of fat metabolism, an imbalance of the regulatory system Bad-kan occurs.

Excess blood cholesterol accumulates in the vascular walls in the form of atherosclerotic plaques. Gradually, the lumen in the vessels narrows, as a result, normal blood circulation cannot be, therefore, the blood supply to the heart deteriorates.

Development mechanism

• The heart is known, pumps blood, but it also badly needs a good blood supply, which means that nutrients and oxygen delivery.
• The heart muscle is nourished by the bloodcoming from two arteries. They pass from the root of the aorta and bend around the heart in the form of a crown. Therefore, they have such a name - coronary vessels.
• Then the arteries are divided into several branches, smaller. Moreover, each of them must feed only its own part of the heart.

  If the lumen of even one vessel narrows slightly, the muscle will begin to experience a lack of nutrition. But if it is completely clogged, then the development of many serious diseases is inevitable.

• Initially, with intense exercise the person will experience slight pain behind the sternum - this is called exertional angina... But muscle metabolism will deteriorate over time, the lumens of the arteries will narrow. Therefore, pains will now appear more often even: with a slight load, then in a horizontal position of the body.
• Together with exertional angina may form along the way chronic heart failure... It is manifested by shortness of breath, severe edema. If a sudden rupture of the plaque occurs, it will lead to the overlap of the remaining lumen of the artery, then myocardial infarctioninevitable.
  It can lead to cardiac arrest and even death, if you do not provide the person with emergency assistance. The severity of the lesion will depend only on where the blockage occurred. In an artery or its branch, and which one. The larger it is, the more serious the consequences for a person will be.
• For the development of a heart attack the lumen should narrow by at least 70%. If this happens gradually, then the heart will still be able to adapt to the decrease in blood volume. But a sharp blockage is very dangerous, it often leads to the death of the patient.

Risk factors

Treatment

There are many treatments for this serious illness. Correct treatment will allow not only to improve the quality of life, but also to significantly extend it.

Treatment methods:

1. conservative - lifelong admission drugs, physiotherapy exercises are indicated, healthy eating, bad habits completely unacceptable now, it is desirable to conduct only healthy image life.
2. surgical - restores vascular patency.

Conservative treatment

A significant role will be played by: decrease in use of animal fats, the diet should contain only healthy foods, leisurely walks are good.

Thus, the affected myocardium will be able to adapt faster to the functional capabilities of the vessels supplying the myocardium with blood.

Drug therapy - the appointment of antianginal drugs. They prevent or completely remove angina attacks. But often conservative treatment is not always effective, then they use surgical techniques correction.

Surgery

Treatment is selected depending on the degree of coronary artery disease:

1. Coronary artery bypass grafting - take a vessel (artery, vein) from the patient and suture to the coronary artery. Thus, a bypass path of blood supply is created. Blood now in sufficient volume will enter the myocardium, eliminating ischemia and attacks of angina pectoris.
2. - a tube (stent) is inserted into the affected vessel, which from now on will prevent further narrowing of the vessel. After installing the stent, the patient will have to undergo long-term antiplatelet therapy. In the first two years, control coronary angiography is shown.

In severe cases, they can offer transmyocardial laser myocardial revascularization... The surgeon directs the laser to the affected area, thereby creating many additional channels of less than 1 ml. Channels, in turn, will drive the growth of new blood vessels... This operation is performed separately, but it can also be combined with coronary artery bypass grafting.

Medication

Medicines should only be prescribed by a doctor.

Their arsenal is quite large, and it is often required to take several drugs of different groups at once:

• nitrates - this is a well-known nitroglycerin, it not only expands the coronary arteries, but also the delivery of blood to the myocardium will significantly improve. Used for unbearable pain, prevention of seizures;
• antiplatelet agents - for the prevention of thrombus formation, dissolution of thrombi: Cardiomagnet, Heparin, Laspirin, etc.;
• beta-blockers - the need for oxygen decreases, normalizes the rhythm, endowed with antiplatelet actions: Vero-Atenolol Metoprolol, Atenolol-Ubfi, Atenolol, etc.;
• calcium antagonists - have wide range actions: hypotensive, antianginal, tolerance to small physical exertion improves: Nifedipine, Isoptin, Verapamil, Veracard, Verapamil-LekT, etc .;
• fibrates and statins - lower blood cholesterol: Simvastatin, Lovastatin, Rosuvastatin, etc.;
• drugs that improve metabolism in the heart muscle - Inosin-Eskom, Riboxin, Inosie-F, etc.

Folk remedies

Before treatment, you should definitely consult with your doctor.

Folk remedies:

Most popular recipes:

1. 1 tbsp. l. flattened hawthorn fruit;
2. 400 ml boiling water.

At night, pour the fruits into a thermos, pour boiling water. Let them insist until morning. Drink 3–4 times a day, 30 ml before meals for 1 hour. Reception for 1 month, then take a break for a month and can be repeated.

1. crush hawthorn;
2. motherwort grass.

Mix in equal proportions: take 5-6 tbsp. l. and pour 1.5 liters of boiling water, wrap it up and let it infuse until warm. Take 0.5 cups 2-4 times a day, preferably before meals, half an hour before meals.

1. leaves of white mistletoe - 1 tbsp. l .;
2. buckwheat flowers - 1 tbsp. l.

Pour 500 ml of boiling water and leave for 9-10 hours. Drink 2-4 tbsp. l. 3-5 times a day.

1. field horsetail - 20 gr.;
2. hawthorn flowers - 20 gr.;
3. bird highlander grass - 10 gr.

Pour 250 ml of boiling water, leave for about an hour, be sure to drain. Drink in small sips throughout the day and can be taken every week.

1. corn root - 40 gr.;
2. medicinal lovage - 30 gr.

Pour boiling water over (cover with water) and cook for 5-10 minutes, insist for an hour. Take 1/4 tbsp. 2-3 times a day, always after meals.

Modern methods of treatment

• Treatment methods are improving, but the principle of treatment remains the same - it is the restoration of blood flow.
  This is achieved in 2 ways: medication, surgical. Drug therapy is the basic basis of treatment, especially for chronic coronary artery disease.
• Treatment prevents the development of some serious forms of coronary artery disease: sudden death, heart attack, unstable angina pectoris. Cardiologists use various drugs: lowering "bad" cholesterol, antiarrhythmic, blood thinners, etc.
  In severe cases, surgical methods are used:
  • Most modern method treatment - this is endovascular surgery... This is the newest direction in medicine that allows you to replace surgical intervention on bloodless without cuts. They are less painful and never cause complications.
    The operation is performed without incisions, a catheter and other instruments are inserted through small punctures in the skin and guided by radiation imaging techniques. This operation is performed on an outpatient basis, even anesthesia is not used in most cases.

Complications and consequences

Complications include:

• the formation of focal cardiosclerosis and diffuse atherosclerotic cardiosclerosis - there is a decrease in functioning cardiomyocytes. In their place, a coarse connective tissue (scar) is formed;
• "Dormant" or "stunned" myocardium - impaired contractility of the left ventricle;
• diastolic, systolic function is disturbed;
• other functions are also impaired: automatism, excitability, contractility, etc .;
• inferiority - cardiomyocytes (energy metabolism of myocardial cells).

Effects:

1. According to statistics, 1/4 of deaths occur precisely because of coronary heart disease.
2. A frequently diagnosed consequence is cardiosclerosis of a diffuse, post-infarction course. The connective tissue, growing, is replaced by a pathogenic fibrous scar with valvular deformation.
3. Myocardial hibernation is an adaptive response. The heart tries to adapt to the existing blood supply, adapts to the existing blood flow.
4. Angina pectoris - begins with insufficient coronary circulation.
5. Diastolic, or systolic left ventricular dysfunction - impaired contractility of the left ventricle. Or it is normal, but the ratio between: filling of diastole and atrial systole is broken.
6. Conduction is impaired and arrhythmia has developed - initiating myocardial contractions are malfunctioning.
7. Heart failure is preceded by: myocardial infarction.

The most dangerous types of coronary artery disease and angina pectoris, which are spontaneous, they can instantly disappear and reappear. They can be transformed into a heart attack or simply copied.

CHD diagnosis - this is not a sentence, but a reason not to lose heart. It is necessary to act and not to waste precious time, but to choose the optimal treatment tactics... A cardiologist will help you with this. This will not only save your life, but also help keep you active, on long years... Health and longevity to all!

RCHD (Republican Center for Healthcare Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols MH RK - 2013

Other angina pectoris (I20.8)

Cardiology

general information

Short description

Approved by the Protocol
Expert Commission on Healthcare Development
dated June 28, 2013

Ischemic heart disease- This is an acute or chronic heart damage caused by a decrease or cessation of blood delivery to the myocardium due to a painful process in the coronary vessels (WHO definition 1959).

Angina pectoris - this is clinical syndrome, manifested by a feeling of discomfort or pain in the chest compressing, oppressive nature, which is localized most often behind the sternum and can radiate to the left arm, neck, lower jaw, epigastric region. The pain is provoked by physical exertion, going out into the cold, eating abundantly, emotional stress; passes at rest or is eliminated by taking sublingual nitroglycerin for a few seconds or minutes.

I. INTRODUCTORY PART

Name: Ischemic heart disease stable exertional angina
Protocol code:

MKB-10 codes:
I20.8 - Other forms of angina pectoris

Abbreviations used in the protocol:
AG - arterial hypertension
AA - antianginal (therapy)
BP - blood pressure
CABG - coronary artery bypass grafting
ALT - alanine aminotransferase
AO - abdominal obesity
ACT - aspartate aminotransferase
CCB - calcium channel blockers
GP - doctors general practice
UPN - upper borderline norm
VPU - Wolff-Parkinson-White syndrome
HCM - hypertrophic cardiomyopathy
LVH - left ventricular hypertrophy
DBP - diastolic blood pressure
DLP - dyslipidemia
ZhE - ventricular premature beats
Ischemic heart disease
BMI - body mass index
ICD - insulin short acting
CAG - coronary angiography
CA - coronary arteries
CPK - creatine phosphokinase
MS - metabolic syndrome
IGT - impaired glucose tolerance
NVII - continuous intravenous insulin therapy
TC - total cholesterol
ACS BPST - acute coronary syndrome without ST elevation
ACS CPST - acute coronary syndrome with ST segment elevation
OT - waist size
SBP - systolic blood pressure
DM - diabetes mellitus
GFR - glomerular filtration rate
ABPM - 24-hour blood pressure monitoring
TG - triglycerides
TIM - the thickness of the intima-media complex
TSH - glucose tolerance test
U3DG - ultrasound doppler
FA - physical activity
FC - functional class
FN - physical activity
RF - risk factors
COPD - chronic obstructive pulmonary disease
CHF - chronic heart failure
HDL cholesterol - high density lipoprotein cholesterol
LDL cholesterol - low density lipoprotein cholesterol
4KB - Percutaneous Coronary Intervention
HR - heart rate
ECG - electrocardiography
EKS - pacemaker
Echocardiography - echocardiography
VE - minute breathing volume
VCO2 is the amount of carbon dioxide emitted per unit of time;
RER (Respiratory Ratio) - VCO2 / VO2 ratio;
BR is the respiratory reserve.
BMS - Non-drug eluting stent
DES - drug eluting stent

Protocol development date: year 2013.
Patient category: adult patients on inpatient treatment with a diagnosis of ischemic heart disease, stable exertional angina.
Protocol users:general practitioners, cardiologists, interventional cardiologists, cardiac surgeons.

Classification

Clinical classification

Table 1. Classification of the severity of stable exertional angina according to the classification of the Canadian Heart Association (Campeau L, 1976)

Diagnostics

II. METHODS, APPROACHES AND PROCEDURES OF DIAGNOSTICS AND TREATMENT

Lab tests:
1. OAK
2. OAM
3. Blood sugar
4. Blood creatinine
5. Total protein
6. ALT
7. Blood electrolytes
8. Lipid spectrum of blood
9. Coagulogram
10. ELISA for HIV (before CAG)
11. ELISA for markers viral hepatitis (before KAG)
12. Ball on i / r
13. Blood for micro-reaction.

Instrumental examinations:
1. ECG
2. EchoCG
3. FG / radiography of OGK
4. EFGDS (by indication)
5. Exercise ECG (VEM, treadmill test)
6. Stress EchoCG (according to indications)
7. Daily monitoring of ECG by Holter (according to indications)
8. Coronary angiography

Diagnostic criteria

Complaints and anamnesis
The main symptom of stable angina is a feeling of discomfort or pain in the chest of a compressing, pressing character, which is localized most often behind the sternum and can radiate to the left arm, neck, lower jaw, and epigastric region.
The main factors provoking chest pain: physical activity - brisk walking, climbing a mountain or stairs, carrying heavy loads; increased blood pressure; cold; plentiful food intake; emotional stress. Usually the pain goes away at rest after 3-5 minutes. or within a few seconds or minutes after taking sublingual nitroglycerin tablets or spray.

table 2 - Symptom complex of angina pectoris

When taking anamnesis, factors should be noted cHD risk: male gender, elderly age, dyslipidemia, hypertension, smoking, diabetes mellitus, increased heart rate, low physical activity, overweight, alcohol abuse.

The conditions that provoke myocardial ischemia or aggravate its course are analyzed:
increasing oxygen consumption:
- noncardiac: hypertension, hyperthermia, hyperthyroidism, intoxication with sympathomimetics (cocaine, etc.), agitation, arteriovenous fistula;
- cardiac: HCM, aortic heart defects, tachycardia.
reducing oxygen supply:
- noncardiac: hypoxia, anemia, hypoxemia, pneumonia, bronchial asthma, COPD, pulmonary hypertension, sleep apnea syndrome, hypercoagulability, polycythemia, leukemia, thrombocytosis;
- cardiac: congenital and acquired heart defects, systolic and / or diastolic dysfunction of the left ventricle.

Physical examination
When examining a patient:
- it is necessary to assess the body mass index (BMI) and waist circumference, determine the heart rate, pulse parameters, blood pressure on both hands;
- you can find signs of lipid metabolism disorders: xanthomas, xanthelasmas, marginal opacification of the cornea of \u200b\u200bthe eye ("senile arch") and stenosing lesions of the main arteries (carotid, subclavian peripheral arteries lower limbs and etc.);
- during physical activity, sometimes at rest, during auscultation, the 3rd or 4th heart sounds can be heard, as well as systolic murmur at the apex of the heart, as a sign of ischemic dysfunction of the papillary muscles and mitral regurgitation;
- pathological pulsation in the precordial region indicates the presence of an aneurysm of the heart or expansion of the borders of the heart due to severe hypertrophy or dilatation of the myocardium.

Instrumental research

Electrocardiography in 12 leads is a mandatory method: diagnosis of myocardial ischemia with stable angina pectoris. Even in patients with severe angina pectoris, changes in the ECG at rest are often absent, which does not exclude the diagnosis of myocardial ischemia. However, the ECG may show signs of coronary heart disease, such as previous myocardial infarction or repolarization disorders. An ECG may be more informative if it is recorded during an attack of pain. In this case, it is possible to identify a displacement of the ST segment during myocardial ischemia or signs of damage to the pericardium. Registration of an ECG during stool and pain is especially indicated if vasospasm is suspected. Other changes can be detected on the ECG, such as left ventricular hypertrophy (LVH), bundle branch block, premature ventricular excitation syndrome, arrhythmias, or conduction disturbances.

Echocardiography: Resting 2D and Doppler echocardiography can rule out other heart conditions, such as valvular defects or hypertrophic cardiomyopathy, and examine ventricular function.

Recommendations for echocardiography in patients stable angina
Class I:
1. Auscultatory changes indicating the presence of valvular heart disease or hypertrophic cardiomyopathy (B)
2. Signs of heart failure (B)
3. Postponed myocardial infarction (B)
4. Blockade of the left bundle branch, Q waves or other significant pathological changes on the ECG (C)

Daily ECG monitoring is shown:
- for the diagnosis of painless myocardial ischemia;
- to determine the severity and duration ischemic changes;
- to identify vasospastic angina or Prinzmetal angina.
- to diagnose rhythm disturbances;
- to assess the heart rate variability.

The criterion for myocardial ischemia during 24-hour ECG monitoring is ST segment depression\u003e 2 mm with a duration of at least 1 min. The duration of ischemic changes according to the data of the CM ECG matters. If the total duration of the ST segment decrease reaches 60 minutes, then this can be regarded as a manifestation of severe CHD and is one of the indications for myocardial revascularization.

Exercise ECG:Stress test is a more sensitive and specific method for diagnosing myocardial ischemia than resting ECG.
Recommendations for an exercise test in patients with stable angina pectoris
Class I:
1. The test should be carried out in the presence of symptoms of angina pectoris and moderate / high probability of coronary heart disease (taking into account age, gender and clinical manifestations) except for those cases when the test cannot be performed due to load intolerance or the presence of changes in the ECG at rest (B).
Class IIb:
1. Presence of ST segment depression at rest ≥1 mm or treatment with digoxin (B).
2. Low probability of having coronary heart disease (less than 10%), taking into account age, gender and the nature of clinical manifestations (B).

Reasons for terminating exercise testing:
1. Onset of symptoms such as chest pain, fatigue, shortness of breath, or intermittent claudication.
2. A combination of symptoms (eg pain) with severe ST segment changes.
3. Patient safety:
a) severe ST segment depression (\u003e 2 mm; if ST segment depression is 4 mm or more, then this is absolute indication to terminate the sample);
b) ST segment elevation ≥2 mm;
c) the appearance of a threatening rhythm disturbance;
d) a persistent decrease in systolic blood pressure by more than 10 mm Hg. Art .;
e) high arterial hypertension (systolic blood pressure over 250 mm Hg or diastolic blood pressure over 115 mm Hg).
4. Achievement of the maximum heart rate can also serve as the basis for termination of the test in patients with excellent load tolerance who do not have signs of fatigue (the decision is made by the doctor at his discretion).
5. Refusal of the patient from further research.

Table 5 - Characteristics of FC in patients with coronary artery disease with stable angina pectoris according to the results of a test with FN (Aronov D.M., Lupanov V.P. et al. 1980, 1982).

Stress echocardiography surpasses the stress ECG in predictive value, has a greater sensitivity (80-85%) and specificity (84-86%) in the diagnosis of coronary artery disease.

Myocardial perfusion scintigraphy with a load. The method is based on the Sapirstein fractional principle, according to which the radionuclide during the first circulation is distributed in the myocardium in quantities proportional to the coronary fraction cardiac output, and reflects the regional distribution of perfusion. The FN test is a more physiological and preferred method of reproducing myocardial ischemia; however, pharmacological tests can be used.

Recommendations for stress echocardiography and myocardial scintigraphy in patients with stable angina pectoris
Class I:
1. The presence of ECG changes at rest, left bundle branch block, ST-segment depression of more than 1 mm, pacemaker or Wolff-Parkinson-White syndrome, which do not allow interpretation of ECG results with stress (B).
2. Ambiguous results of ECG with exercise with its acceptable tolerance in a patient with a low probability of coronary heart disease, if the diagnosis is in doubt (B)
Class IIa:
1. Determination of the localization of myocardial ischemia before myocardial revascularization (percutaneous intervention on the coronary arteries or coronary artery bypass grafting) (B).
2. Alternative exercise ECG with appropriate equipment, personnel and facilities (B).
3. An alternative to exercise ECG when the likelihood of coronary heart disease is low, for example, in women with atypical chest pain (B).
4. Evaluation functional value moderate stenosis of the coronary arteries detected by angiography (C).
5. Determination of the localization of myocardial ischemia when choosing the method of revascularization in patients who underwent angiography (B).

Recommendations for the use of echocardiography or myocardial scintigraphy with pharmacological test in patients with stable angina pectoris
Class I, IIa and IIb:
1. The indications listed above, if the patient cannot perform an adequate load.

Multispiral cT scan heart and coronary vessels:
- prescribed for the examination of men aged 45-65 years and women aged 55-75 years without established CVDs for the purpose of early detection initial signs coronary atherosclerosis;
- as an initial diagnostic test in outpatient setting in patients aged< 65 лет с атипичными болями в грудной клетке при отсутствии установленного диагноза ИБС;
- as an additional diagnostic test in aged patients< 65 лет с сомнительными результатами нагрузочных тестов или наличием традиционных коронарных ФР при отсутствии установленного диагноза ИБС;
- for the differential diagnosis between CHF ischemic and non-ischemic genesis (cardiopathy, myocarditis).

Magnetic resonance imaging of the heart and blood vessels
Stress MRI can be used to detect dobutamine-induced LV wall asynergy or adenosine-induced perfusion disorders. The technique is recent and is therefore less well understood than other non-invasive imaging techniques. The sensitivity and specificity of LV contractility disorders detected by MRI is 83% and 86%, respectively, and perfusion disorders - 91% and 81%. Stress perfusion MRI has similarly high sensitivity but reduced specificity.

Magnetic resonance coronary angiography
MRI is characterized by a lower efficiency rate and less accuracy in the diagnosis of coronary artery disease than MSCT.

Coronary angiography (CAT) - the main method for diagnosing the state of the coronary bed. CAG allows you to choose the optimal method of treatment: medication or myocardial revascularization.
Indications for the appointment of CAG for a patient with stable angina pectoris when deciding whether to perform PCI or CABG:
- severe angina pectoris III-IV FC, persisting with optimal antianginal therapy;
- signs of severe myocardial ischemia according to the results of non-invasive methods;
- the patient has a history of episodes of VS or dangerous ventricular rhythm disturbances;
- disease progression according to the dynamics of non-invasive tests;
- early development severe angina pectoris (FC III) after MI and myocardial revascularization (up to 1 month);
- dubious results of non-invasive tests in persons with socially significant professions (public transport drivers, pilots, etc.).

Currently, there are no absolute contraindications for the appointment of CAG.
Relative contraindications for CAG:
- Sharp renal failure
- Chronic renal failure (blood creatinine level 160-180 mmol / l)
- Allergic reactions on contrast agent and iodine intolerance
- Active gastrointestinal bleeding, exacerbation of peptic ulcer disease
- Severe coagulopathy
- Severe anemia
- Acute violation of cerebral circulation
- Severe mental disorder of the patient
- Serious comorbidities that significantly shorten the life of the patient or dramatically increase the risk of subsequent treatment interventions
- Refusal of the patient from possible further treatment after the study (endovascular intervention, CABG)
- Severe lesion of peripheral arteries, limiting arterial access
- Decompensated heart failure or acute pulmonary edema
- Malignant hypertension, poorly amenable to drug treatment
- Intoxication with cardiac glycosides
- Severe violation of electrolyte metabolism
- Fever of unknown etiology and acute infectious diseases
- Infective endocarditis
- Exacerbation of severe noncardiological chronic disease

Radiographic recommendations chest in patients with stable angina pectoris
Class I:
1. Chest X-ray is indicated in the presence of symptoms of heart failure (C).
2. Chest X-ray is justified if there are signs of pulmonary involvement (B).

Fibrogastroduodenoscopy (FGDS) (according to indications), research on Helicobtrcter Pylori (according to indications).

Indications for specialist consultation
Endocrinologist - diagnostics and treatment of disorders of glycemic status, treatment of obesity, etc., teaching the patient the principles diet food, transfer to treatment with short-acting insulin before elective surgical revascularization;
Neurologist - the presence of symptoms of brain damage (acute disorders of cerebral circulation, transient disorders of cerebral circulation, chronic forms of vascular pathology of the brain, etc.);
Oculist - the presence of symptoms of retinopathy (according to indications);
Angiosurgeon- diagnostics and treatment recommendations for atherosclerotic lesions of peripheral arteries.

Laboratory diagnostics

Class I (all patients)
1. Fasting lipid levels, including total cholesterol, LDL, HDL, and triglycerides (B)
2. Fasting glycemia (B)
3. General analysis blood, including determination of hemoglobin and leukocyte formula (B)
4. Creatinine level (C), calculation of creatinine clearance
5. Indicators of function thyroid gland (according to indications) (C)

Class IIa
Oral glucose load test (B)

Class IIb
1. Highly sensitive C-reactive protein (B)
2. Lipoprotein (a), ApoA and ApoB (B)
3. Homocysteine \u200b\u200b(B)
4. HbAlc (B)
5. NT-BNP

Table 4 - Assessment of lipid spectrum indicators

List of basic and additional diagnostic measures

Basic research
1. Complete blood count
2. Determination of glucose
3. Determination of creatinine
4. Determination of creatinine clearance
5. Definition of ALT
6. Definition of PTI
7. Determination of fibrinogen
8. Definition of MHO
9. Determination of total cholesterol
10 definition of LDL
11 definition of HDL
12 determination of triglycerides
13. Determination of potassium / sodium
14.Determination of calcium
15.General urine analysis
16.ECG
17.3XOK
18.EKG test with exercise (VEM / treadmill)
19 stress echocardiography

Additional research
1. Glycemic profile
2. X-ray of the chest organs
3. EFGDS
4. Glycated hemoglobin
5 .. Oral glucose load test
6. NT-proBNP
7. Determination of HF-CRP
8. Definition of ABC
9. Definition of APTT
10. Determination of magnesium
11. Determination of total bilirubin
12. CM AD
13.CM ECG Holter
14. Coronary angiography
15. Myocardial perfusion scintigraphy / SPECT
16. Multispiral computed tomography
17. Magnetic resonance imaging
18. PET

Differential diagnosis

Differential diagnosis

Table 6 - Differential diagnosis of chest pain

The clinical picture suggests the presence of three signs:
- typical angina pectoris that occurs with FN (less often - angina pectoris or dyspnea at rest);
- a positive result of an ECG with FN or other stress tests (depression of the ST segment on the ECG, myocardial perfusion defects on scintigrams);
- normal coronary arteries on CAG.

Treatment abroad

Undergo treatment in Korea, Israel, Germany, USA

Get advice on medical tourism

Treatment

Treatment goals:
1. To improve the prognosis and prevent the occurrence of myocardial infarction and sudden death, and, accordingly, increase life expectancy.
2. Reduce the frequency and intensity of angina attacks and thus improve the patient's quality of life.

Treatment tactics

Non-drug treatment:
1. Information and education of the patient.

2. Quitting smoking.

3. Individual recommendations on permissible physical activity depending on the FC of angina pectoris and the state of LV function. Exercise is recommended as they lead to an increase in TFN, a decrease in symptoms and have a beneficial effect on BW, lipid levels, blood pressure, glucose tolerance and insulin sensitivity. Moderate loads for 30-60 minutes ≥5 days a week depending on the FC of angina pectoris (walking, light jogging, swimming, cycling, skiing).

4. Recommended diet: eating a wide range of foods; control over the calorie content of food, to avoid obesity; increased consumption of fruits and vegetables, as well as whole grains and breads, fish (especially fatty varieties), lean meats and low-fat dairy products; replace saturated fats and trans fats with monounsaturated and polyunsaturated fats from vegetable and marine sources, and reduce total fat (of which less than one third should be saturated) to less than 30% of total calories consumed, and reduce salt intake , with an increase in blood pressure. Body mass index (BMI) less than 25 kg / m is considered normal and recommends weight loss with a BMI of 30 kg / m 2 or more, as well as with a waist circumference of more than 102 cm in men or more than 88 cm in women, since weight loss can improve many obesity-related risk factors.

5. Alcohol abuse is unacceptable.

6. Treatment of concomitant diseases: in hypertension - reaching the target blood pressure<130 и 80 мм.рт.ст., при СД - достижение количественных критериев компенсации, лечение гипо- и гипертиреоза, анемии.

7. Recommendations for sexual activity - sexual intercourse can provoke the development of angina pectoris, so nitroglycerin can be taken before it. Phosphodiesterase inhibitors: sildenafil (Viagra), tadafil, and vardenafil, used to treat sexual dysfunction, should not be used in combination with prolonged-release nitrates.

Drug treatment
Medicines that improve the prognosis in patients with angina pectoris:
1. Antiplatelet drugs:
- acetylsalicylic acid (dose 75-100 mg / day - long-term).
- patients with aspirin intolerance are indicated to use clopidogrel 75 mg per day as an alternative to aspirin
- dual antiplatelet therapy with aspirin and oral use of ADP receptor antagonists (clopidogrel, ticagrelor) should be applied up to 12 months after 4KB, with a strict minimum for patients with BMS -1 month, patients with DES - 6 months.
- Gastric protection using proton pump inhibitors should be carried out during dual antiplatelet therapy in patients at high risk of bleeding.
- in patients with clear indications for the use of oral anticoagulants (atrial fibrillation on the CHA2DS2-VASc scale ≥2 or the presence of mechanical valve prostheses), they should be used in addition to antiplatelet therapy.

2. Lipid-lowering drugs that reduce LDL-C levels:
- Statins. The most studied statins in coronary artery disease are atorvastatin 10-40 mg and rosuvastatin 5-40 mg. The dose of any of the statins should be increased, observing an interval of 2-3 weeks, since the optimal effect of the drug is achieved during this period. The target level is determined by LDL-C - less than 1.8 mmol / l. Monitoring indicators in treatment with statins:
- it is necessary to initially take a blood test for lipid profile, ACT, ALT, CPK.
- after 4-6 weeks of treatment, the tolerability and safety of treatment should be assessed (patient complaints, repeated blood tests for lipids, ACT, ALT, CPK).
- when titrating doses, first of all, they are guided by the tolerance and safety of treatment, and secondly, by the achievement of target lipid levels.
- with an increase in the activity of liver transaminases of more than 3 VPNs, it is necessary to repeat the blood test again. It is necessary to exclude other causes of hyperenzymemia: alcohol intake the day before, cholelithiasis, exacerbation of chronic hepatitis, or other primary and secondary liver diseases. The reason for the increase in CPK activity can be damage to skeletal muscles: intense physical activity the day before, intramuscular injections, polymyositis, muscular dystrophies, trauma, surgery, myocardial damage (MI, myocarditis), hypothyroidism, CHF.
- if ACT, ALT\u003e 3 VLT, CPK\u003e 5 VLN, statins are canceled.
- An inhibitor of intestinal absorption of cholesterol - ezetimibe 5-10 mg once a day - inhibits the absorption of food and biliary cholesterol in the villous epithelium of the small intestine.

Indications for the appointment of ezetimibe:
- in the form of monotherapy for the treatment of patients with a heterozygous form of FHC who cannot tolerate statins;
- in combination with statins in patients with a heterozygous form of FHC, if the level of LDL-C remains high (more than 2.5 mmol / L) against the background of the highest doses of statins (simvastatin 80 mg / day, atorvastatin 80 mg / day) or poor tolerance of high doses of statins. The fixed combination is the Ineji preparation, which contains - ezetimibe 10 mg and simvastatin 20 mg in one tablet.

3. β-blockers
The positive effects of using this group of drugs are based on a decrease in myocardial oxygen demand. Bl-selective blockers include: atenolol, metoprolol, bisoprolol, nebivolol, non-selective ones - propranolol, nadolol, carvedilol.
β - blockers should be preferred in patients with coronary artery disease with: 1) the presence of heart failure or left ventricular dysfunction; 2) concomitant arterial hypertension; 3) supraventricular or ventricular arrhythmias; 4) postponed myocardial infarction; 5) the presence of a clear connection between physical activity and the development of an angina attack
The effect of these drugs in stable angina pectoris can only be counted on if, when prescribed, a clear blockade of β-adrenergic receptors is achieved. For this, it is necessary to maintain a resting heart rate within 55-60 beats / min. In patients with more pronounced angina pectoris, the heart rate can be reduced to 50 beats / min, provided that such bradycardia does not cause unpleasant sensations and does not develop AV block.
Metoprolol succinate 12.5 mg twice a day, if necessary, increasing the dose to 100-200 mg per day when used twice.
Bisoprolol - starting with a dose of 2.5 mg (with the existing decompensation of CHF - from 1.25 mg) and, if necessary, increasing to 10 mg, with a single appointment.
Carvedilol - a starting dose of 6.25 mg (with hypotension and symptoms of CHF 3.125 mg) in the morning and evening with a gradual increase to 25 mg twice.
Nebivolol - starting with a dose of 2.5 mg (with existing CHF decompensation - from 1.25 mg) and, if necessary, increasing to 10 mg, once a day.

Absolute contraindications to the appointment of beta-blockers in coronary artery disease - severe bradycardia (heart rate less than 48-50 per minute), atrioventricular block 2-3 degrees, sick sinus syndrome.

Relative contraindications - bronchial asthma, COPD, acute heart failure, severe depression, peripheral vascular disease.

4. ACE inhibitors or ARA II
ACE inhibitors are prescribed for patients with coronary artery disease in the presence of signs of heart failure, arterial hypertension, diabetes mellitus and the absence of absolute contraindications to their appointment. Drugs with a proven effect on long-term prognosis are used (ramipril 2.5-10 mg once a day, perindopril 5-10 mg once a day, fosinopril 10-20 mg per day, zofenopril 5-10 mg, etc.). With intolerance to ACE inhibitors, angiotensin II receptor antagonists can be prescribed with a proven positive effect on the long-term prognosis in IHD (valsartan 80-160 mg).

5. Calcium antagonists (calcium channel blockers).
They are not the main agents in the treatment of coronary artery disease. May relieve symptoms of angina pectoris. The effect on survival and complication rate in contrast to beta-blockers has not been proven. Prescribed for contraindications to the appointment of b-blockers or their insufficient effectiveness in combination with them (with dihydropyridines, except for the short-acting nifedipine). Another indication is vasospastic angina.
Currently, long-acting CCBs (amlodipine) are recommended for the treatment of stable angina pectoris; they are used as second-line drugs if symptoms persist with b-blockers and nitrates. CCB should be given preference in case of concomitant: 1) obstructive pulmonary diseases; 2) sinus bradycardia and severe violations of atrioventricular conduction; 3) variant angina (Prinzmetal).

6. Combination therapy (fixed combinations) patients with stable angina pectoris II-IV FC is carried out according to the following indications: impossibility of selecting an effective monotherapy; the need to enhance the effect of monotherapy (for example, during a period of increased physical activity of the patient); correction of unfavorable hemodynamic changes (for example, tachycardia caused by CCBs of the dihydropyridine group or nitrates); with a combination of angina pectoris with hypertension or heart rhythm disturbances that are not compensated for in cases of monotherapy; in case of intolerance to the generally accepted doses of AA drugs by patients with monotherapy (in order to achieve the required AA effect, small doses of drugs can be combined; addition to the main AA drugs, other agents are sometimes prescribed (potassium channel activators, ACE inhibitors, antiplatelet agents).
When conducting AA therapy, one should strive for almost complete elimination of anginal pain and return of the patient to normal activity. However, therapeutic tactics do not give the desired effect in all patients. In some patients with an exacerbation of coronary artery disease, the severity of the condition is sometimes exacerbated. In these cases, consultation of cardiac surgeons is necessary in order to provide the patient with cardiac surgery.

Relief and prevention of anginal pain:
Angianal therapy solves symptomatic problemsin restoring the balance between the need for and delivery of oxygen to the myocardium.

Nitrates and nitrate-like. With the development of an attack of angina pectoris, the patient must stop physical activity. The drug of choice is nitroglycerin (NTG and its inhaled forms) or short-acting isosorbide dinitrate, taken sublingually. Angina prophylaxis is achieved with various forms of nitrates, including oral isosorbide di- or mononitrate tablets, or (less commonly) a once-daily nitroglycerin transdermal patch. Long-term therapy with nitrates is limited by the development of tolerance to them (i.e., a decrease in the effectiveness of the drug with prolonged, frequent use), which appears in some patients, and the withdrawal syndrome - with an abrupt discontinuation of drugs (symptoms of exacerbation of coronary artery disease).
The undesirable effect of developing tolerance can be prevented by creating a nitrate-free gap of several hours, usually while the patient is asleep. This is achieved by intermittent administration of short-acting nitrates or special forms of retard mononitrates.

If channel inhibitors.
Inhibitors of If channels of sinus node cells - Ivabradine, selectively reducing sinus rhythm, has a pronounced antianginal effect, comparable to the effect of b-blockers. Recommended for patients with contraindications to b-blockers or inability to take b-blockers due to side effects.

Recommendations for pharmacotherapy to improve prognosis in patients with stable angina pectoris
Class I:
1. Acetylsalicylic acid 75 mg / day. in all patients in the absence of contraindications (active gastrointestinal bleeding, allergy to or intolerance to aspirin) (A).
2. Statins in all patients with ischemic heart disease (A).
3. ACE inhibitors in the presence of arterial hypertension, heart failure, left ventricular dysfunction, myocardial infarction with left ventricular dysfunction or diabetes mellitus (A).
4. β-AB inside patients after a history of myocardial infarction or with heart failure (A).
Class IIa:
1. ACE inhibitors in all patients with angina pectoris and a confirmed diagnosis of coronary heart disease (B).
2. Clopidogrel as an alternative to aspirin in patients with stable angina pectoris who cannot take aspirin, for example, due to allergies (B).
3. Statins in high doses in the presence of high risk (cardiovascular mortality\u003e 2% per year) in patients with proven coronary artery disease (B).
Class IIb:
1. Fibrates with low levels of high density lipoproteins or high levels of triglycerides in patients with diabetes mellitus or metabolic syndrome (B).

Recommendations for antianginal and / or anti-ischemic therapy in patients with stable angina pectoris.
Class I:
1. Short-acting nitroglycerin for angina relief and situational prophylaxis (patients should receive adequate instructions for the use of nitroglycerin) (B).
2. To evaluate the effectiveness of β, -AB and titrate its dose to the maximum therapeutic dose; evaluate the feasibility of using a long-acting drug (A).
3. In case of poor tolerance or low efficiency of β-AB, prescribe monotherapy with AK (A), long-acting nitrate (C).
4. If β-AB monotherapy is not effective enough, add dihydropyridine AA (B).
Class IIa:
1. If β-AB is poorly tolerated, prescribe a sinus node channel I inhibitor - ivabradine (B).
2. If monotherapy with AK or combination therapy with AK and β-AB is ineffective, replace AK with prolonged nitrate. Avoid developing nitrate tolerance (C).
Class IIb:
1. Drugs of metabolic type of action (trimetazidine MB) can be prescribed to enhance antianginal efficacy of standard drugs or as an alternative to them in case of intolerance or contraindications to use (B).

Essential drugs
Nitrates
- Nitroglycerin tab. 0.5 mg
- Isosorbide mononitrate cap. 40 mg
- Isosorbide mononitrate cap. 10-40 mg
Beta blockers
- Metoprolol succinate 25 mg
- Bisoprolol 5 mg, 10 mg
AIF inhibitors
- Ramipril tab. 5 mg, 10 mg
- Zofenopril 7.5 mg (preferred for CKD - \u200b\u200bGFR less than 30 ml / min)
Antiplatelet agents
- Acetylsalicylic acid tab. coated 75, 100 mg
Lipid-lowering drugs
- Rosuvastatin tab. 10 mg

Additional medications
Nitrates
- Isosorbide dinitrate tab. 20 mg
- Isosorbide dinitrate aerosus dose
Beta blockers
- Carvedilol 6.25 mg, 25 mg
Calcium antagonists
- Amlodipine tab. 2.5 mg
- Diltiazem cap. 90 mg, 180 mg
- Verapamil tab. 40 mg
- Nifedipine tab. 20 mg
AIF inhibitors
- Perindopril tab. 5 mg, 10 mg
- Captopril tab. 25 mg
Angiotensin II receptor antagonists
- Valsartan tab. 80 mg, 160 mg
- Candesartan tab. 8 mg, 16 mg
Antiplatelet agents
- Clopidogrel tab. 75 mg
Lipid-lowering drugs
- Atorvastatin tab. 40 mg
- Fenofibrate tab. 145 mg
- Tofisopam tab. 50mg
- Diazepam tab. 5mg
- Diazepam amp 2ml
- Spironolactone tab. 25 mg, 50 mg
- Ivabradine tab. 5 mg
- Trimetazidine tab. 35 mg
- Esomeprazole lyophilisate amp. 40 mg
- Esomeprazole tab. 40 mg
- Pantoprazole tab. 40 mg
- Sodium chloride 0.9% solution 200 ml, 400 ml
- Dextrose 5% solution 200 ml, 400 ml
- Dobutamine * (loading tests) 250 mg / 50 ml
Note: * Medicines not registered in the Republic of Kazakhstan, imported under a one-time import permit (Order of the Ministry of Health of the Republic of Kazakhstan dated December 27, 2012 No. 903 “On approval of the maximum prices for medicines purchased within the guaranteed volume of free medical care for 2013”).

Surgical intervention
Invasive treatment of stable angina pectoris is indicated primarily in patients at high risk of complications. revascularization and drug treatment do not differ in the frequency of myocardial infarction and mortality. The effectiveness of PCI (stenting) and drug therapy has been compared in several meta-analyzes and a large RCT. In most meta-analyzes, there was no reduction in mortality, there was an increase in the risk of nonfatal periprocedural MI, and a decrease in the need for re-revascularization after PCI.
Balloon angioplasty in combination with stent placement to prevent restenosis. Stents coated with cytostatics (paclitaxel, sirolimus, everolimus and others) reduce the incidence of restenosis and repeated revascularization.
It is recommended to use stents that meet the following specifications:
Drug eluting coronary stent
1. Baolon-expandable stent with drug eluting everolimus on a rapid-change delivery system 143 cm long. Mater cobalt-chrome alloy L-605, wall thickness 0.0032 ". Balloon material - Pebax. Passage profile 0.041". The proximal shaft is 0.031 ", the distal shaft is 034". The nominal pressure is 8 atm for 2.25-2.75 mm, 10 atm for 3.0-4.0 mm. Burst pressure - 18 atm. Length 8, 12, 15, 18, 23, 28, 33, 38 mm. Diameters 2.25, 2.5, 2.75, 3.0, 3.5, 4.0 mm. Dimensions on request.
2. The material of the stent is cobalt-chromium alloy L-605. Cylinder material - Fulcrum. Coated with a mixture of Zotarolimus drug and BioLinx polymer. Cell thickness 0.091mm (0.0036 "). Delivery system 140 cm long. Proximal shaft size 0.69 mm, distal shaft 0.91 mm. Nominal pressure: 9 atm. Burst pressure 16 atm. For diameters 2.25- 3.5 mm, 15 atm. For a diameter of 4.0 mm. Dimensions: diameter 2.25, 2.50, 2.75, 3.00, 3.50, 4.00 and stent length (mm) -8, 9, 12, 14, 15, 18, 22, 26, 30, 34, 38.
3. Stent material - platinum-chromium alloy. The share of platinum in the alloy is at least 33%. The share of nickel in the alloy is no more than 9%. The thickness of the stent walls is 0.0032 ". The drug coating of the stent consists of two polymers and a drug. The thickness of the polymer coating is 0.007 mm. The profile of the stent on the delivery system is no more than 0.042" (for a stent with a diameter of 3 mm). The maximum diameter of the expanded stent cell is at least 5.77 mm (for a stent with a diameter of 3.00 mm). Stent diameters - 2.25 mm; 2.50 mm; 2.75 mm; 3.00 mm; 3.50 mm, 4.00 mm. Available stent lengths - 8 mm, 12 mm, 16 mm, 20 mm, 24 mm, 28 mm, 32 mm, 38 mm. Nominal pressure - not less than 12 atm. Limiting pressure - not less than 18 atm. The profile of the tip of the balloon of the delivery system of the stent is not more than 0.017 ". The working length of the balloon catheter on which the stent is mounted is not less than 144 cm. The length of the tip of the balloon of the delivery system is 1.75 mm. 5-blade technology of the balloon placement. X-ray contrast markers made of platinum - iridium alloy The length of the radiopaque markers is 0.94 mm.
4. Stent material: cobalt-chromium alloy, L-605. Passive coating: amorphous silicone-carbide, active coating: biodegradable polylactide (L-PLA, Poly-L-Lactic Acid, PLLA) including Sirolimus. The thickness of the stent frame with a nominal diameter of 2.0-3.0 mm is not more than 60 microns (0.0024 "). Crossing stent profile - 0.039 "(0.994 mm). Stent length: 9, 13, 15, 18, 22, 26, 30 mm. Nominal stent diameter: 2.25 / 2.5 / 2.75 / 3.0 / 3.5 / 4.0 mm. Distal end diameter (entry profile) - 0.017 "(0.4318 mm). The working length of the catheter is 140 cm. The nominal pressure is 8 atm. The calculated burst pressure of the balloon is 16 atm. Stent diameter 2.25 mm at a pressure of 8 atmospheres: 2.0 mm. Stent diameter 2.25 mm at 14 atmospheres pressure: 2.43 mm.

No drug eluting coronary stent
1. Balloon-expandable stent on a rapid delivery system 143 cm. Stent material: non-magnetic cobalt-chromium alloy L-605. Cylinder material - Pebax. Wall thickness: 0.0032 "(0.0813 mm). Diameters: 2.0, 2.25, 2.5, 2.75, 3.0, 3.5, 4.0 mm. Lengths: 8, 12, 15, 18, 23, 28 mm. Stent-on-balloon profile 0.040" (stent 3.0x18 mm). The length of the working surface of the balloon beyond the edges of the stent (balloon overhang) is no more than 0.69 mm. Compliance: nominal pressure (NP) 9 atm., Design burst pressure (RBP) 16 atm.
2. The material of the stent is cobalt-chromium alloy L-605. Cell thickness 0.091 mm (0.0036 "). Delivery system 140 cm long. Proximal shaft size 0.69 mm, distal shaft 0.91 mm. Nominal pressure: 9 atm. Burst pressure 16 atm. For diameters 2.25- 3.5 mm, 15 atm. For a diameter of 4.0 mm. Dimensions: diameter 2.25, 2.50, 2.75, 3.00, 3.50, 4.00 and stent length (mm) - 8, 9, 12, 14, 15, 18, 22, 26, 30, 34, 38.
3. Stent material - stainless steel 316L on a quick delivery system 145 cm long. M-coated distal shaft (except for the stent). The delivery system design is a three-blade balloon boat. Stent wall thickness, no more than 0.08 mm. The stent design is open cell. Low profile 0.038 "for 3.0 mm stent. Possibility to use a guide catheter with 0.056" / 1.42 mm ID. Nominal cylinder pressure 9 atm for a diameter of 4 mm and 10 atm for diameters from 2.0 to 3.5 mm; burst pressure 14 atm. Diameter of the proximal shaft - 2.0 Fr, distal - 2.7 Fr, Diameters: 2.0; 2.25; 2.5; 3.0; 3.5; 4.0 Length 8; ten; thirteen; 15; eighteen; 20; 23; 25; 30 mm.
Compared with drug therapy, dilatation of the coronary arteries does not lead to a decrease in mortality and the risk of myocardial infarction in patients with stable angina pectoris, but increases exercise tolerance, decreases the incidence of angina pectoris and hospitalizations. Before PCI, the patient receives a loading dose of clopidogrel (600 mg).
After implantation of non-drug eluting stents, combination therapy with aspirin 75 mg / day is recommended for 12 weeks. and clopidogrel 75 mg / day, and then continue taking one aspirin. If a drug eluting stent is implanted, the combination therapy is continued up to 12-24 months. If the risk of vascular thrombosis is high, then therapy with two antiplatelet agents can be continued for more than a year.
Combination therapy with antiplatelet agents in the presence of other risk factors (age\u003e 60 years, taking corticosteroids / NSAIDs, dyspepsia or heartburn) requires prophylactic proton pump inhibitors (eg rabeprazole, pantoprazole, etc.).

Contraindications to myocardial revascularization.
- Borderline stenosis (50-70%) of CA, except for the trunk of the LCA, and the absence of signs of myocardial ischemia in non-invasive examination.
- Insignificant CA stenosis (< 50%).
- Patients with stenosis of 1 or 2 coronary artery without pronounced proximal narrowing of the anterior descending artery, who have mild symptoms of angina pectoris or no symptoms, and have not received adequate drug therapy.
- High operational risk of complications or death (possible mortality\u003e 10-15%) unless it is offset by the expected significant improvement in survival or QoL.

Coronary artery bypass grafting
There are two indications for CABG: improved prognosis and decreased symptoms. Reducing mortality and the risk of developing myocardial infarction has not been conclusively proven.
Consultation with a cardiac surgeon is necessary to determine the indications for surgical revascularization within the framework of a collegial decision (cardiologist + cardiac surgeon + anesthesiologist + interventional cardiologist).

Table 7 - Indications for revascularization in patients with stable angina pectoris or latent ischemia

OMT \u003d optimal drug therapy;

PRK \u003d fractional blood flow reserve;
PNA \u003d anterior descending artery;
LCA \u003d left coronary artery;
PCB \u003d percutaneous coronary intervention.

Recommendations for myocardial revascularization in order to improve the prognosis in patients with stable angina pectoris
Class I:
1. Coronary artery bypass grafting with severe stenosis of the main trunk of the left coronary artery or significant narrowing of the proximal segment of the left descending and circumflex coronary arteries (A).
2. Coronary artery bypass grafting in severe proximal stenosis of 3 major coronary arteries, especially in patients with reduced left ventricular function or rapidly emerging or widespread reversible myocardial ischemia during functional tests (A).
3. Coronary artery bypass grafting in stenosis of one or 2 coronary arteries in combination with severe narrowing of the proximal left anterior descending artery and reversible myocardial ischemia in non-invasive studies (A).
4. Coronary artery bypass grafting in case of severe stenosis of the coronary arteries in combination with impaired left ventricular function and the presence of a viable myocardium according to non-invasive tests (B).
Class II a:
1. Coronary artery bypass grafting with stenosis of one or 2 coronary arteries without pronounced narrowing of the left anterior descending artery in patients who have suffered sudden death or persistent ventricular tachycardia (B).
2. Coronary artery bypass grafting with severe stenosis of 3 coronary arteries in patients with diabetes mellitus, in whom signs of reversible myocardial ischemia are determined during functional tests (C).

Preventive actions
Key lifestyle interventions include smoking cessation and tight blood pressure control, advice on diet and weight control, and encouraging physical activity. Although general practitioners will be responsible for the long-term management of this patient population, these measures will be more likely to be implemented if initiated during the hospital stay. In addition, the benefits and importance of lifestyle changes must be explained and offered to the patient - who is a key player - prior to discharge. However, life habits are not easy to change, and implementing and following these changes is a long-term task. In this regard, close collaboration between cardiologist and general practitioner, nurses, rehabilitation specialists, pharmacists, nutritionists, physiotherapists is critical.

To give up smoking
Patients who quit smoking reduced their mortality compared to those who continued to smoke. Smoking cessation is the most effective of all secondary prevention measures and therefore every effort must be made to achieve this. However, it is common for patients to resume smoking after discharge, and ongoing support and advice is needed during the rehabilitation period. The use of nicotine substitutes, buproprion, and antidepressants may be helpful. A smoking cessation protocol must be adopted by every hospital.

Diet and weight control
The current prevention guidelines recommend:
1.reasonable balanced diet;
2. control of the calorie content of foods to avoid obesity;
3. an increase in the consumption of fruits and vegetables, as well as whole grains, fish (especially fatty varieties), lean meat and low-fat dairy products;
4. Replace saturated fats with monounsaturated and polyunsaturated fats from vegetable and marine sources, and reduce the total amount of fat (of which less than one third should be saturated) to less than 30% of the total calorie intake;
5. restriction of salt intake with concomitant arterial hypertension and heart failure.

Obesity is a growing problem. The current EOC guidelines define a body mass index (BMI) of less than 25 kg / m 2 as the optimal level, and recommends weight loss with a BMI of 30 kg / m 2 or more, as well as with a waist circumference of more than 102 cm in men or more than 88 cm in women, as weight loss can improve many of the risk factors associated with obesity. However, weight loss has not been found to reduce mortality by itself. Body mass index \u003d weight (kg): height (m 2).

Physical activity
Regular exercise is beneficial for patients with stable coronary artery disease. In patients, it can reduce feelings of anxiety associated with life-threatening illnesses and increase self-confidence. It is recommended that you do thirty minutes of moderate-intensity aerobic exercise at least five times a week. Each step of increasing peak power exercise results in a reduction in the risk of all-cause mortality in the range of 8-14%.

Blood pressure control
Pharmacotherapy (beta blockers, ACE inhibitors, or ARBs - angiotensin receptor blockers) in addition to lifestyle changes (reduced salt intake, increased physical activity, and weight loss) usually helps achieve these goals. Additional drug therapy may also be needed.

Further management:
Rehabilitation of patients with stable angina pectoris
Dosed physical activity allows:
- to optimize the functional state of the patient's cardiovascular system by activating cardiac and extracardiac compensation mechanisms;
- increase the TFN;
- to slow down the progression of ischemic heart disease, to prevent the occurrence of exacerbations and complications;
- return the patient to professional work and increase his ability to self-service;
- reduce the dose of antianginal drugs;
- improve the patient's well-being and quality of life.

Contraindications to the appointment of dosed physical training are:
- unstable angina pectoris;
- cardiac arrhythmias: constant or frequently occurring paroxysmal form of atrial fibrillation or atrial flutter, parasystole, pacemaker migration, frequent polytopic or group extrasystole, II-III degree AV block;
- uncontrolled hypertension (blood pressure\u003e 180/100 mm Hg);
- pathology of the musculoskeletal system;
- history of thromboembolism.

Psychological rehabilitation.
Virtually every patient with stable angina needs psychological rehabilitation. On an outpatient basis, with the availability of specialists, the most accessible classes are rational psychotherapy, group psychotherapy (coronary club) and autogenous training. If necessary, patients can be prescribed psychotropic drugs (tranquilizers, antidepressants).

The sexual aspect of rehabilitation.
With intimacy in patients with stable angina pectoris, due to an increase in heart rate and blood pressure, conditions may arise for the development of an anginal attack. Patients should be aware of this and take antianginal drugs on time to prevent angina attacks.
Patients with high FC angina pectoris (IIІ-IV) should adequately assess their capabilities in this regard and take into account the risk of CVD development. Patients with erectile dysfunction, after consulting a doctor, can use type 5 phosphodiesterase inhibitors: sildenafil, vardanafil, tardanafil, but taking into account contraindications: taking prolonged nitrates, low blood pressure, TFN.

Ability to work.
An important stage in the rehabilitation of patients with stable angina pectoris is the assessment of their ability to work and rational employment. The ability to work of patients with stable angina pectoris is determined mainly by its FC and the results of stress tests. In addition, one should take into account the state of the contractile ability of the heart muscle, the possible presence of signs of CHF, a history of myocardial infarction, as well as CAG indicators, indicating the number and degree of coronary artery disease.

Dispensary observation.
All patients with stable angina pectoris, regardless of age and the presence of concomitant diseases, must be registered at the dispensary. Among them, it is advisable to single out a high-risk group: a history of myocardial infarction, periods of instability in the course of ischemic heart disease, frequent episodes of painless myocardial ischemia, serious cardiac arrhythmias, heart failure, severe concomitant diseases: diabetes mellitus, cerebrovascular accidents, etc. Dispensary observation implies systematic visits to a cardiologist ( therapist) once every 6 months with the obligatory instrumental examination methods: ECG, Echo KG, stress tests, determination of the lipid profile, as well as ECG, ABPM monitoring according to Holter's indications. An essential point is the appointment of adequate drug therapy and correction of RF.

Indicators of the effectiveness of treatment and the safety of diagnostic and treatment methods described in the protocol:
Antianginal therapy is considered effective if it is possible to completely eliminate angina pectoris or transfer the patient from a higher FC to a lower FC while maintaining good QOL.

Hospitalization

Indications for hospitalization
Maintaining a high functional class of stable angina pectoris (III-IV FC), despite full drug treatment.

Information

Sources and Literature

1. Minutes of meetings of the Expert Commission on Healthcare Development of the Ministry of Health of the Republic of Kazakhstan, 2013
   1. 1. ESC Guidelines on the management of stable angina pectoris. European Heart Journal. 2006; 27 (11): I341-8 I. 2. BHOK. Diagnosis and treatment of stable angina pectoris. Russian recommendations (second revision). Cardiovascular ter. and prophylaxis. 2008; Appendix 4. 3. Recommendations for myocardial revascularization. European Society of Cardiology 2010.

Information

III. ORGANIZATIONAL ASPECTS OF THE PROTOCOL IMPLEMENTATION

List of protocol developers:
1. Berkinbaev S.F. - Doctor of Medical Sciences, Professor, Director of the Research Institute of Cardiology and Internal Diseases.
2. Dzhunusbekova G.A. - Doctor of Medical Sciences, Deputy Director of the Research Institute of Cardiology and Internal Diseases.
3. Musagalieva A.T. - Ph.D., Head of the Department of Cardiology, Research Institute of Cardiology and Internal Diseases.
4. Salikhova Z.I. - Junior Researcher, Department of Cardiology, Research Institute of Cardiology and Internal Diseases.
5. Amantaeva A.N. - Junior Researcher, Department of Cardiology, Research Institute of Cardiology and Internal Diseases.

Reviewers:
Abseitova SR. - Doctor of Medical Sciences, Chief Cardiologist of the Ministry of Health of the Republic of Kazakhstan.

No Conflict of Interest Statement: absent.

Indication of the conditions for revising the protocol: The protocol is revised at least once every 5 years, or upon receipt of new data on the diagnosis and treatment of the corresponding disease, condition or syndrome.

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Ischemic heart disease and angina pectoris in ICD-10 have their place. There are diseases that are based on disturbances in the process of blood flow to the heart muscle. Such ailments are called ischemic heart disease. A separate place in this group is occupied by angina pectoris, as it signals that the patient's condition is dangerous. The disease itself is not fatal, but it is a precursor to ailments that are fatal.

Accepted international classification

In international documentation, IHD occupies categories from I20 to I25. I20 is angina pectoris, also called angina pectoris. If it is not stable, then the number 20.0 is indicated. In this case, it can be increasing, as well as angina pectoris, both first-emerging and in a progressive stage. For a disease that is also characterized by spasms, the number 20.1 is set. In this case, the disease can be angiospastic, variant, spasmodic, or Prinzmetal's syndrome. The remaining varieties of the disease are indicated under the number 20.8, and if the pathology has not been clarified, then the code 20.9 is used.

If the patient has an acute stage of myocardial infarction, then this is section I21. This includes the specified acute illness or established within a month (but no more). Some side effects after a heart attack are excluded, as well as an ailment suffered in the past, chronic, lasting more than a month, and also subsequent. In addition, this section does not include postinfarction syndromes.

If the patient has a recurrent myocardial infarction, then this is section I22. Such a code is used for all types of myocardial infarction, which is localized anywhere, but occurs within 28 days from the moment of the first attack. This includes recurrent, recurrent, and growing species. But a chronic condition is excluded. Section I23 is used for some recurrent complications of acute myocardial infarction.

The classification includes other forms of acute ischemic heart disease. All information on this is contained in section I24. If the patient has a coronary thrombosis, which does not lead to myocardial infarction, then the number 24.0 is written. But at the same time, thrombosis in a chronic form or lasting more than 28 days is excluded. For Dressler's syndrome the number is 24.1. The rest of the forms of acute ischemic heart disease are written under the number 24.8, and if the disease is not fully specified, then the code 24.9 is used.

For chronic coronary artery disease, the code I25 is used. If the patient has atherosclerotic disease of the heart and blood vessels, then the number 25.0 is written. If only atherosclerosis of the heart, then 25.1. If myocardial infarction was transferred in the past, then number 25.2 is written. For cardiac aneurysms, the code 25.3 is used. If the patient has a coronary arterial aneurysm, the number 25.4 is indicated. However, the congenital form of this disease is excluded. If the patient has ischemic cardiomyopathy, then number 25.5 is used. When ischemia occurs without visible symptoms, a diagnosis is made with a code 25.6. Other forms of ischemic heart disease with a chronic course are signed with the number 25.8, and if the patient's condition is not specified, then the code 25.9 is used.

Existing types of ailment

Angina is a type of heart disease. This ailment is considered specific, so that it can be determined by some features. Pathology develops due to the fact that the blood flow to the heart decreases, as the coronary arteries narrow. Depending on how much this process is disturbed, various forms of the disease are distinguished.

If the patient's heart muscle tissue is gradually destroyed, then this is necrosis. In this case, there may be a widespread, transmural or superficial infarction. If the myocardium is not destroyed, then this condition is called ischemia. Here angina pectoris of tension and rest is distinguished. The first form is characterized by the occurrence of severe physical exertion. This includes unstable and stable forms of angina pectoris. As for angina pectoris at rest, it occurs even without physical exertion. There are 2 main subspecies - vasospastic angina and Prinzmetal.

Angina itself is:

1. 1. Voltage. It is characterized by the appearance of pains of a pressing nature in the retrosternal region, when a person has intense physical activity. The pain can be given to the left side of the chest, left arm, scapular region, neck. As soon as such unpleasant sensations appear, it is necessary to stop any load. After a while, the pain syndrome will pass on its own. Additionally, you can take nitrates. If the pathological condition persists, then exertional angina is stable.
2. 2. Rest. Pain syndrome behind the sternum appears when a person is at rest. This happens in two cases. First, if a coronary vessel reflexively spasms. This is the cause of ischemic disease. Secondly, it is necessary to take into account Prinzmetal's angina. This is a special variety that arises abruptly due to the fact that the lumens of the coronary arteries overlap. For example, this happens due to detached plaques.
3. 3. Unstable. This term denotes either exertional angina, which gradually progresses, or resting angina, which is variable. If the pain syndrome cannot be stopped by taking nitrates, then the pathological process can no longer be controlled, and this is very dangerous.

Causes and treatment of pathology

Such pathologies are characterized by the following general symptoms:

• feeling of tightness behind the sternum and in the left side of the chest;
• the course of the disease is manifested by attacks;
• unpleasant symptoms occur sharply, and not only during physical exertion, but also at rest;
• the attack usually lasts half an hour, and if more, then it is already a heart attack;
• relieves the symptoms of an attack Nitroglycerin or other similar nitrate-based drugs.

A key moment in the development of ischemic heart disease is the narrowing of the lumen in the coronary arteries.

Due to its multifactorial action and comparative safety, Siofor is not always taken for its intended purpose - for the treatment of diabetes. The property of the drug to stabilize, and in some cases, to reduce the growing weight, makes it possible to use it for weight loss. Research data show that the best effect is observed in those with metabolic syndrome and a high proportion of visceral fat.

According to reviews, Siofor without a diet allows you to lose up to 4.5 kg. In addition, it can reduce appetite and improve metabolism, so it makes it easier to lose weight with a low-calorie diet and exercise.

In addition to the effect on weight, the feasibility of taking Siofor for the treatment of the following diseases is currently being considered:

1. With gout, Siofor reduces the manifestations of the disease and reduces the level of uric acid. During the experiment, patients took 1500 mg of metformin for 6 months, improvements were observed in 80% of cases.
2. A positive effect of metformin has also been noted in fatty liver disease, but the final conclusion has not yet been presented. So far, it has been reliably established that the drug increases the effectiveness of the diet for fatty hepatosis.
3. In polycystic ovary disease, medication is used to improve ovulation and restore the menstrual cycle.
4. There are suggestions that metformin may have anti-cancer effects. Preliminary studies have shown a reduced risk of cancer in type 2 diabetes.

Despite the fact that Siofor has a minimum of contraindications and is sold without a prescription, you should not self-medicate. Metformin works well only in patients with insulin resistance, so it is advisable to take tests, at least glucose and insulin, and determine the HOMA-IR level.

More \u003e\u003e Blood test for insulin - why take and how to do it correctly?

Siofor for weight loss how to apply

Sugar level

Siofor can be taken for weight loss not only for diabetics, but also for conditionally healthy overweight people. The action of the drug is based on reducing insulin resistance. The lower it is, the lower the insulin level, the easier it is to break down fatty tissues. With a lot of excess weight, low mobility, malnutrition, insulin resistance is present in one way or another, so you can count on Siofor to help you lose a little extra pounds. The best results are expected in people with male obesity - on the abdomen and sides, with the bulk of fat located around the organs and not under the skin.

Evidence of insulin resistance - an overestimated level of insulin in the vessels, is determined by an analysis of venous blood, carried out on an empty stomach. You can donate blood in any commercial laboratory without a doctor's referral. On the issued form, the reference (target, normal) values \u200b\u200bmust be indicated, with which the result can be compared.

It is assumed that the drug affects the appetite from several sides:

1. Influences the mechanisms of regulation of hunger and satiety in the hypothalamus.
2. Increases the concentration of leptin, a hormone that regulates energy metabolism.
3. Improves insulin sensitivity so that cells receive energy on time.
4. Regulates fat metabolism.
5. Presumably, it eliminates the failure of circadian rhythms, thereby normalizing digestion.

Do not forget that at first there may be problems with the gastrointestinal tract. When the body gets used to it, these symptoms should stop. If there is no improvement for more than 2 weeks, try replacing Siofor with a long-acting metformin, for example, Glucophage Long. In case of complete drug intolerance, daily exercise and a low-carbohydrate diet will help to cope with insulin resistance - a menu for type 2 diabetes.

In the absence of contraindications, the drug can be taken continuously for a long time. Dosage according to the instructions: start with 500 mg, gradually bring it to the optimal dose (1500-2000 mg). Stop drinking Siofor when the goal of losing weight is achieved.

Drug analogues

Russia has accumulated extensive experience in using Siofor in diabetes mellitus. At one time he was even better known than the original Glucophage. Siofor's price is not high, from 200 to 350 rubles for 60 tablets, so there is no point in taking cheaper substitutes.

Medicines that are complete analogues of Siofor, tablets differ only in auxiliary ingredients:

All analogues have a dosage of 500, 850, 1000; Metformin-Richter - 500 and 850 mg.

When Siofor, despite the diet, does not reduce sugar, it makes no sense to replace it with analogs. This means that diabetes has passed to the next stage, and the pancreas began to lose its function. The patient is prescribed pills that stimulate the synthesis of insulin, or hormone injections.

Siofor or Glucophage - which is better?

The first trade name of Metformin to receive a patent was Glucophage. He is considered the original drug. Siofor is a high quality, effective generic. Usually analogs are always worse than the originals, in this case the situation is different. Thanks to high quality and competent promotion, Siofor was able to achieve recognition of patients with diabetes and endocrinologists. Now he is prescribed only slightly less frequently than Glucophage. According to reviews, there is no difference between the drugs, both are excellent at lowering sugar.

The only fundamental difference between these drugs: Glucophage has a version with a longer action. According to research data, the prolonged-release drug can reduce the risk of discomfort in the digestive organs, therefore, if Siofor tablets are poorly tolerated, they can be replaced with Glucophage Long.

Siofor or Russian Metformin - which is better?

In most cases, Russian medicines with metformin are only conditionally such. The tablets and packaging are produced by a domestic firm, which also carries out issuing control. But the pharmaceutical substance, the same metformin, is purchased in India and China. Considering that these drugs are not much cheaper than the original Glucophage, it makes no sense to take them, despite the declared identity.

Admission rules

Siofor tablets, taken on an empty stomach, aggravate digestive problems, so they are taken during or after meals, and the most abundant meals are chosen. If the dosage is low, the tablets can be taken once at dinner. At a dose of 2000 mg Siofor is divided into 2-3 doses.

Duration of treatment

Siofor is taken as much as required according to the indications. With diabetes mellitus, they drink it for years: first alone, then with other hypoglycemic drugs. Long-term use of metformin can lead to a B12 deficiency, so diabetics are advised to daily use foods high in vitamin: beef and pork liver, sea fish. It is advisable to take an analysis for cobalamin annually, and if there is a lack of it, take a course of the vitamin.

If the drug was taken to stimulate ovulation, it is discontinued immediately after pregnancy. When losing weight - as soon as the effectiveness of the medicine decreases. If a diet is followed, usually six months of admission is sufficient.

Maximum dose

The optimal dosage for diabetes mellitus is 2000 mg of metformin, since this amount is characterized by the best ratio of "hypoglycemic effect - side effects". Studies on the effect of Siofor on weight were carried out with 1500 mg of metformin. Without risk to health, the dose can be increased to 3000 mg, but you need to be prepared that digestive disorders may occur.

Alcohol compatibility

The instructions for the medicine say about the inadmissibility of acute alcohol intoxication, as it can cause lactic acidosis. At the same time, small doses equivalent to 20-40 g of alcohol are allowed. Do not forget that ethanol worsens the compensation of diabetes mellitus.

Effects on the liver

Siofor's action also affects the liver. It reduces the synthesis of glucose from glycogen and non-carbohydrate compounds. In the overwhelming majority, this effect is safe for the organ. In extremely rare cases, the activity of liver enzymes increases, hepatitis develops. If you stop taking Siofor, both violations go away on their own.

If liver disease is not accompanied by insufficiency, metformin is allowed, and with fatty hepatosis, it is even recommended for use. The drug prevents lipid oxidation, lowers triglycerides and cholesterol levels, and reduces the supply of fatty acids to the liver. According to research, it triples the effectiveness of the diet prescribed for fatty hepatosis.