Class IX. Circulatory system diseases (I 20-25)
Coronary heart disease I 20 Angina pectoris (angina pectoris) I 20.0 Unstable angina I 20.1 Angina pectoris with documented spasm I 20.8 Other forms of myocardial ischemia I 20.9 Unspecified angina (I 20-25)
Coronary heart disease I 25 Chronic coronary heart disease I 25.0 Atherosclerotic cardiovascular disease, as described I 25.1 Atherosclerotic heart disease I 25.2 Past myocardial infarction I 25.3 Heart aneurysm I 25.4 Aneurysm of the coronary artery I 25.5 Ischemic cardiomyopathy I 25.6 Bessimic 25.8 Other forms of coronary heart disease I 25.9 Chronic coronary heart disease, unspecified
In clinical practice, it is more convenient to use the WHO classification, since it takes into account different forms of the disease. In healthcare, official statistics use the ICD-10.
The disease has an acute and chronic course. Depending on its nature and severity of symptoms, there are such forms of coronary heart disease:
- angina pectoris;
- myocardial infarction and post-infarction cardiosclerosis;
- sudden coronary death;
- painless or dumb.
The described type of pathology is divided into several subgroups in accordance with the factors that provoke pain attacks. Chronic coronary heart disease refers to stable angina (tension). They differentiate into 4 functional classes according to severity (I-IV). Signs of this angina pectoris occur in response to emotional or physical stress.
An unstable coronary heart disease happens:
- first arising;
- early postoperative;
Other forms of angina pectoris:
- variant (Prinzmetal angina).
Often pain attacks are complicated by arrhythmia. It is considered a condition equivalent to stable and spontaneous angina pectoris. Arrhythmia combines the clinical manifestations of left ventricular heart failure:
This type of disease can be large and small focal, depending on the extent of necrosis of muscle tissue. Acute coronary heart disease or heart attack requires immediate hospitalization, otherwise severe complications develop, including death. One of the common consequences of such an attack is cardiosclerosis (myocardial scarring). He is diagnosed about 2 months after a heart attack.
An unforeseen condition that is believed to provoke electrical myocardial instability. If coronary heart disease has led to instant death or death within 6 hours after the attack, sudden coronary death is diagnosed. In other situations, the cause of the problem may be other myocardial pathologies – heart attack, cardiosclerosis or complicated angina pectoris.
This type of disease does not cause any symptoms and there are no complaints. It is more difficult to detect than the above variants of coronary heart disease, so the pathology slowly progresses and often provokes dangerous consequences. It is important to visit a cardiologist regularly for prevention. Latent chronic ischemic disease is an insidious disease that is accidentally detected even in young people. Without treatment, it can lead to sudden death.
- Causes of IHD
- Clinical forms of coronary heart disease (CHD)
- Description of the disease
- Risk Factors for Coronary Heart Disease
- Varieties of coronary heart disease
- Coronary heart disease – symptoms
- Signs of Coronary Heart Disease
- Diagnosis and treatment
- Pain in coronary heart disease
- Treatment of the disease
- Case study
- What is the risk of coronary heart disease?
- How is coronary heart disease
Causes of IHD
Coronary heart disease is often considered inevitable for people who have reached a certain age. Indeed, the highest incidence of disease is observed in people older than 50 years. However, not all people get coronary artery disease at the same time, for someone it occurs earlier, for someone later, and someone survives to advanced years without encountering this problem.
- bad habits (smoking, alcoholism);
- overweight, obesity;
- lack of physical activity;
- the wrong diet;
- genetic predisposition;
- some concomitant diseases, for example, diabetes mellitus, hypertension.
All these reasons can play a role, but the immediate precursor of coronary atherosclerosis is an imbalance in the various types of cholesterol in the blood and an extremely high concentration of so-called bad cholesterol (or low density lipoproteins). With a value of this concentration above a certain limit, a person with a high degree of probability has arteriosclerosis of the vessels, and as a result, coronary heart disease.
A certain negative factor is the male gender. Statistics say that coronary heart disease is much more likely to develop in men than in women. This is due to the fact that women in the body produce female hormones that protect blood vessels and prevent the deposition of cholesterol in them. However, after the onset of female menopause, the number of estrogen produced by the female body decreases, and therefore the number of women suffering from coronary heart disease increases sharply, almost comparing with the number of men suffering from this disease.
Separately, one should stop such a premise of the disease as an improper diet. As you know, the largest percentage of the incidence of coronary heart disease is in developed countries. Specialists mainly associate this fact with the fact that in Europe and America, people consume more animal fats, as well as simple, easily digestible carbohydrates. And this, together with a sedentary lifestyle, leads to obesity, to an excess of cholesterol in the blood.
Doctors knowingly warn about products containing bad cholesterol. Such products include fatty meats, butter, cheese, eggs, caviar. The amount of these products in the diet of each person should be limited, they should not be consumed every day, or in small quantities.
Although, on the other hand, only a small fraction of bad cholesterol enters the body from the outside, the rest is produced in the liver. So the significance of this factor should not be exaggerated, not to mention the fact that harmful cholesterol can be called very conditionally, since it takes part in many metabolic processes.
The pathology under consideration occurs due to atherosclerosis of the coronary arteries of varying degrees. The lumen of the blood vessel may be partially narrowed due to cholesterol plaque or completely blocked. Against the background of progressive atherosclerotic lesions, other causes of coronary heart disease (coronary heart disease) also join:
- coronary artery spasm;
- obstruction of the coronary vessels.
There are still discussions about the causes of “silent” myocardial ischemia. Over the past few years, our American colleagues have been trying to disprove the existence of this pathology, passing off changes on the ECG as post-infarction aneurysms, etc.
It is suggested that a similar form of coronary heart disease occurs against the background of damage to the nerve fibers responsible for the perception of pain impulses. Factors leading to polyneuropathy are:
- prolonged alcohol abuse,
- long history of smoking,
- hereditary hyperlipidemia (increase in the concentration of cholesterol and other fats in the blood),
- previous myocardial infarction.
No less rare factors leading to pathology are:
- over 60 years old
- a constitutionally determined high pain threshold (in other words, a person does not feel weak impulses),
- hypertonic disease,
- prolonged stress
- sedentary lifestyle,
- chronic overwork and lack of sleep.
Painless myocardial ischemia develops mainly against the background of atherosclerotic lesions of the coronary vessels, associated with a decrease in the elasticity and flexibility of the vascular walls, as well as a significant narrowing of the arterial lumen due to plaques of atherosclerotic origin. Atherosclerotic plaques are formations that consist of a fat mixture containing predominantly cholesterol, calcium and other substances.
The formation of plaque in the vessels leads to impaired blood circulation and blood supply to the myocardium. Often the cause of the latent ischemic form is a vascular spasm that occurs during hypothermia, stress and other hypersensitivity to external factors. People with diabetes are often prone to developing a painless ischemic form.
Equally important is individual sensitivity to pain. Patients with ischemia are characterized by reduced tactile and pain sensitivity, so sometimes explicit pain symptoms are simply not perceived by the patient. Some people, regardless of pathology, have a rather high pain threshold, so they simply do not feel the pain syndrome characteristic of an ischemic attack.
- Nicotine addiction, including any type of tobacco consumption – chewing, smoking cigars, pipes or cigarettes;
- Elevated cholesterol levels, contributing to thrombosis and the formation of plaques in the vessels;
- Hereditary factor – experts have officially proven that painless ischemia (and not only) can be inherited;
- Arterial hypertension;
- Exposure to frequent stresses and violent psycho-emotional experiences;
- Diabetes mellitus – a pathological condition representing a relative or absolute insulin deficiency;
- Distinctive personality traits like increased aggressiveness, impatience and thirst for competition, etc .;
- Hypodynamic lifestyle (immobility);
- The abuse of fatty foods;
- Men over 40, women over 55.
If painless myocardial ischemia develops in parallel with diabetes, then the causes of this tandem are explained by diabetic neuropathy. An increase in the pain threshold can be of an age-related nature and can be caused by a high content of endorphins in the blood.
Clinical forms of coronary heart disease (CHD)
- Type I is more often diagnosed in people with coronary stenosis who were not previously bothered by arrhythmias, angina pectoris, heart attack attacks, etc .;
- Type II painless ischemia is usually diagnosed in patients who have had heart attacks in the past, but do not suffer from angina attacks;
- Type III is typical for patients with vivid symptoms of angina attacks or their equivalents.
1. Coronary heart disease (coronary heart disease) – a condition in which an imbalance between the oxygen demand of the myocardium and its delivery leads to myocardial hypoxia and the accumulation of metabolic products; the main reason for this is CA atherosclerosis (“coronary heart disease”).
2. Angina pectoris – discomfort in the chest and adjacent anatomical structures caused by acute myocardial ischemia.
3. Stable angina pectoris – a chronic type of transient angina pectoris provoked by physical activity or emotions and stopped within a few minutes at rest; episodes of angina pectoris are often associated with transient ST segment depression, but persistent myocardial damage does not develop.
4. Variant angina pectoris – typical angina pectoris, usually dormant, which develops due to spasm of the spacecraft, and not due to an increase in myocardial oxygen demand; episodes are often accompanied by transient fluctuations in the ST segment (usually elevation).
5. Unstable angina pectoris – a type of angina pectoris with an increase in the frequency and duration of seizures, provoked by a lesser load or developing at rest; if untreated, myocardial infarction often develops.
6. Mute ischemia – asymptomatic episodes of myocardial ischemia; can be detected by monitoring an electrocardiogram (ECG) or using other instrumental methods.
7. Myocardial infarction (MI) – a site of myocardial necrosis, usually due to prolonged cessation of blood flow; most often develops due to acute thrombosis at the site of atherosclerotic stenosis of the spacecraft; may be the first clinical manifestation of coronary heart disease, or it is preceded by angina pectoris.
8. Acute coronary syndrome (ACS) – unstable angina pectoris or developing myocardial infarction – rupture or erosion of an atherosclerotic plaque with varying degrees of thrombosis at the site of development of the defect with distal occlusion of the affected coronary vessel.
Coronary heart disease (CHD) occurs in various clinical forms; chronic stable angina pectoris, unstable (progressive) angina pectoris, painless (asymptomatic, mute) myocardial ischemia, vasospastic angina pectoris, Syndrome X (microvascular angina), MI, sudden death and chronic heart failure (HF).
IHD can make its debut acutely – MI or even sudden death, but often it develops gradually, turning into a chronic form. In such cases, one of its main manifestations is angina pectoris.
According to the Framingham study, angina pectoris is the first symptom of coronary heart disease in men in 40,7% of cases, in women – in 56,5%.
Stable angina pectoris has various classes of severity (Table 1). The “functional class” (FC) of stable angina pectoris can change dynamically under the influence of antianginal therapy, invasive interventions, or spontaneously.
Table 1. The severity classes of stable angina according to the classification of the Canadian Association of I Cardiologists (no Campeau L. 1976)
“Normal daily physical activity” (walking or climbing stairs) does not cause angina pectoris. pain occurs only when performing a very intense, or very fast, or prolonged load, as well as during rest shortly after performing such a load.
“A slight limitation of normal physical activity”, which means the occurrence of angina pectoris when walking fast or climbing stairs. after eating or in the cold. or in windy weather. or with emotional stress. or in the first few hours after waking up; while walking a distance gt; 200 m (two blocks) on flat terrain or while climbing stairs more than one flight at a normal pace under normal conditions
“Noticeable restriction of physical activity”: an attack of angina pectoris occurs as a result of a quiet walk at a distance of one to two blocks (100-200 m) on flat terrain or when climbing stairs one flight at a normal pace under normal conditions.
“The inability to perform any type of physical activity without causing unpleasant sensations”: angina can occur at rest.
The term “ACS” refers to any group of clinical signs or symptoms that make it possible to suspect acute myocardial infarction or unstable angina. It includes the concepts of acute myocardial infarction, myocardial infarction with and without ST segment elevation on an ECG, myocardial infarction diagnosed by changes in enzymes and other biomarkers, by late ECG signs, and unstable angina pectoris.
ACS is mainly used as a preliminary diagnosis when a patient is admitted to a hospital and indicates the urgent use of active treatment methods that can reduce the risk of severe outcomes – sudden death, the transition of ACS to a large MI.
Acute myocardial infarction (MI) is the most dangerous form of coronary heart disease (CHD).
It is this disease that primarily leads to high mortality and disability of the population in many countries of the world, including in Russia. Currently, in Russia, for every 100 of the population, 000 men and 330 women die every year from myocardial infarction.
A reduction in mortality in MI is achieved through the use of progressive and effective treatment methods in clinical practice, including thrombolytic therapy (TLT), transluminal balloon angioplasty (TBA), and pharmacotherapy with new generation drugs (antiplatelet agents, lipid-lowering drugs, beta-blockers, angiotensin inhibitors (angiotensin inhibitors) ACE), angiotensin receptor blockers, etc.).
In the nineties of the last century, not all patients received adequate treatment for myocardial infarction. However, with an increase (up to 80%) in the number of patients receiving optimal treatment during acute myocardial infarction, whether endovascular, surgical or medication, a 40% reduction in mortality from CVD can be expected.
Posted by Konstantin Mokanov
Description of the disease
Everyone knows that the purpose of the heart muscle (myocardium) is to supply the body with oxygen-rich blood. However, the heart itself needs blood circulation. Arteries that deliver oxygen to the heart are called coronary. There are two such arteries; they extend from the aorta. Inside the heart, they branch out into many smaller ones.
However, the heart does not just need oxygen, it needs a lot of oxygen, much more than other organs. This situation is simply explained – because the heart works constantly and with a huge load. And if a person may not especially feel the manifestations of oxygen deficiency in other organs, then a lack of oxygen in the heart muscle immediately leads to negative consequences.
Circulatory failure in the heart can occur for only one reason – if the coronary arteries leak a little blood. This condition is called “coronary heart disease” (CHD).
In the vast majority of cases, narrowing of the vessels of the heart occurs due to the fact that they are clogged. Vascular spasm, increased blood viscosity and a tendency to form blood clots also play a role. However, the main cause of IHD is coronary arteriosclerosis.
Atherosclerosis was previously considered a disease of the elderly. However, now this is far from the case. Now, atherosclerosis of the blood vessels of the heart can also occur in middle-aged people, mainly in men. With this disease, the vessels are clogged with deposits of fatty acids, forming the so-called atherosclerotic plaques.
They are located on the walls of blood vessels and, narrowing their lumen, inhibit blood flow. If this situation occurs in the coronary arteries, the result is an insufficient supply of oxygen to the heart muscle. Heart disease can develop imperceptibly for many years, not particularly manifesting, and not causing much concern to a person, except in some cases.
Risk Factors for Coronary Heart Disease
There are circumstances predisposing to the occurrence of the pathology in question. The development of coronary heart disease is triggered by the following factors:
- elderly age;
- male gender;
- arterial hypertension ;
- liver dysfunction;
- tendency to atherosclerosis.
Coronary heart disease is more common in people who lead an unhealthy lifestyle. It occurs against the background:
- irrational nutrition;
- drinking alcohol;
- physical inactivity;
- non-compliance with the regime of work and rest.
Varieties of coronary heart disease
In clinical practice, several types of coronary heart disease are distinguished. In most cases, coronary heart disease manifests itself in the form of angina pectoris. Angina pectoris is an external manifestation of coronary heart disease, accompanied by severe chest pain. However, there is also a painless form of angina pectoris. With her, the only manifestation is fatigue and shortness of breath even after minor physical exercises (walking/climbing stairs several floors).
If bouts of pain occur during physical exertion, then this indicates the development of angina pectoris. However, in some people with coronary heart disease, chest pains appear spontaneously, without any connection with physical activity.
Also, the nature of the changes in the symptoms of angina pectoris may indicate whether coronary disease develops or not. If coronary heart disease does not progress, then this condition is called stable angina pectoris. A person with stable angina pectoris, subject to certain rules of behavior and with appropriate supportive therapy, can live for several decades.
It’s a completely different matter when angina attacks become harder and harder over time, and the pain is caused by less and less physical exertion. Such angina is called unstable. This condition is a cause for alarm, because unstable angina pectoris inevitably ends in myocardial infarction, or even death.
A vasospastic angina pectoris or Prinzmetall angina pectoris is also allocated to a specific group. This angina pectoris is caused by a spasm of the coronary arteries of the heart. Often spastic angina occurs in patients suffering from coronary arteriosclerosis. However, this kind of angina pectoris may not be combined with such a sign.
Depending on the severity, angina pectoris is divided into functional classes.
|Class||Physical activity restrictions||What are the stress conditions for heart attacks?|
|I||no||at high intensity|
|II||small||at medium (walking to a distance of more than 500 m, climbing to the third floor)|
|III||pronounced||at low (walking to a distance of 100-200 m, climbing to the second floor)|
|IV||very high||at very low (with any walking, daily activities) or at rest|
Coronary heart disease – symptoms
The main criterion for painless ischemia of the heart muscle is the absence of any discomfort on the part of the heart. Often, even minor changes in hemodynamic parameters (blood pressure, pulse) do not occur.
Over time, symptoms of worsening blood supply to the heart muscle may appear, such as:
- arrhythmias: AV blockade, extrasystoles,
- bradycardia (pulse reduction),
- cyanosis in the nasolabial triangle, hands and feet,
- feeling of heartburn or pressure in the stomach,
- dyspnea attacks
- fluctuation in system pressure.
- Clinical options for the course of pathology
Cardiologists in their practice observe four types of the course of painless myocardial ischemia, which are based on Kohn’s classification:
- The first is the most common and is observed in 60% of cases of pathology. Symptoms of classical angina pectoris are combined with “mute” seizures in a ratio of 1: 3.
- The second – detected in 12,5-13% of patients, is characterized by the detection of an asymptomatic form of pathology during ECG recording. Often, the patient complains of arrhythmias, and he has registered changes typical of a chronic heart attack. Or myocardial necrosis becomes the cause of death and an after-fact is detected during the autopsy.
- The third – in which periods of undetected ischemia end with a typical heart attack with a bright pain syndrome. Hidden circulatory disturbance is detected usually by accident during Holter ECG monitoring.
- Fourth – signs of painless ischemia are detected only against the background of stress tests.
A typical clinical manifestation of the presented disease is a characteristic pain syndrome localized in the sternum. The remaining signs of coronary heart disease are nonspecific, so they are not always associated with the described disease. With the painless form of pathology, complaints are completely absent, and the general condition of a person remains normal for a long time. Other symptoms of coronary artery disease:
- shortness of breath, especially during physical exertion;
- a feeling of interruptions in the work of the heart, a violation of its rhythm;
- dizziness and nausea;
- swelling of the lower extremities;
- fainting or blurred consciousness.
The described pathology is accompanied by discomfort not only in the chest area. Often coronary artery disease causes pain in other parts of the body:
Unpleasant sensations can be of any nature (stitching, pulling or crushing). At first, the pain is not felt for long, for several seconds, and then it subsides. Gradually, coronary heart disease progresses, and extensive areas of the myocardium are damaged. This leads to prolonged attacks, during which the symptom in question intensifies.
The very name of such an ischemic form indicates asymptomatic, therefore the very first symptoms are due to the complete absence of any pain characteristic of cardiovascular pathologies. Practice shows that patients have various variants of the course of such a pathology. Some patients do not feel the onset of a heart attack or ischemia, and the presence of such pathological conditions is detected by them completely by accident during an ECG or during a preoperative stress test. The first symptoms in such patients may manifest as various arrhythmias or sudden coronary death.
In another group of patients, a similar ischemic form occurs without pain, but with the onset of a heart attack, characteristic pain nevertheless appears. In such a clinical course, it is very difficult to suspect pathology, therefore, the patient usually learns about the pathology by chance during an ECG. The situation is even more complicated if, with such a course of ischemia, the patient has a high pain threshold, since this is fraught with latent heart attack.
Signs of Coronary Heart Disease
Many people do not pay for signs of coronary heart disease, although they are fairly obvious. For example, this is fatigue, shortness of breath, after physical activity, pain and tingling in the heart. Some patients believe that “it should be so, because I am no longer young/not young.” However, this is an erroneous point of view.
In addition, coronary heart disease can manifest itself and other unpleasant symptoms, such as arrhythmias, dizziness, nausea, fatigue. Heartburn and abdominal cramps may occur.
Diagnosis and treatment
Holter ECG monitoring, electrocardiostimulation through the esophagus, stress tests like treadmill or bicycle ergometry, pharmacological tests with dobutamine or dipyridamole, radionuclide techniques, multispiral tomography, coronary angiography, stress echocardiography, and others. is hereditary in nature, transmitted from the next of kin. The patient’s lifestyle is also taken into account: does he abuse alcohol, does he have a nicotine addiction, etc.
The treatment of ischemia of the painless form is non-drug, drug and cardiosurgical in nature. Non-drug therapy involves daily physical activity in the form of cardio training. It can be medical gymnastics, training exercises, swimming or walking. The same methods include nutrition correction, involving the exclusion of fatty and salty foods, an increase in the diet of raw vegetables, fresh fruits, fish and grains.
- calcium antagonists – they are used to dilate blood vessels, to slow down the processes of calcium penetration into blood vessels and myocardium. Such drugs are often prescribed if there are contraindications to β-blockers or their inefficiency;
- β-blockers – they slow down the heartbeat and dilate blood vessels;
- nitrates – drugs that relieve pain during an attack.
The treatment of ischemia involves the use of ACE inhibitors, whose action is aimed at lowering blood pressure. Hypocholesterolemic drugs are also prescribed for patients, designed to lower cholesterol levels in the blood. As additional therapy, diuretics and antiarrhythmic drugs are used to normalize the heart rhythm.
If drug treatment is powerless, then resort to cardiac surgery. Typically, patients undergo coronary artery bypass grafting. This is the restoration of myocardial blood supply through surgical intervention, which involves the creation of a bypass vessel to provide blood to the ischemic site.
Such treatment is carried out in case of damage to the main coronary artery and multiple vascular lesions, accompanied by diseases such as diabetes. Also, patients with ischemia undergo coronary angioplasty, which involves the installation of a special stent inside the coronary vessel in order to expand its lumen for full blood flow.
Based on my own observations, I can argue that in 90-95% of cases “silent” myocardial ischemia is a spontaneous find detected on routine medical examinations, in preparation for operations, when contacting a doctor due to other somatic pathologies. In order not to miss the disease, I recommend that my patients periodically undergo a scheduled examination with ECG registration.
Those with symptoms of atherosclerosis, coronary heart disease should visit a doctor at least once every two months. Persons who have reached the age of 50 must perform an ECG twice a year, and after 60 years – once a quarter.
During the first acquaintance with the patient, the doctor collects an anamnesis of life and disease, clarifies the presence of risk factors leading to painless myocardial ischemia, measures blood pressure, performs pulse counting, percussion and auscultation of the heart.
Laboratory methods for the diagnosis of coronary heart disease include a clinical analysis of blood, urine, a biochemical blood test with specification of lipid profile, troponins, ALT, AST, CPK, myoglobin.
The first stage of instrumental examination of patients is the registration of an ECG with further recording during the performance of stress tests: bicycle ergometry, treadmill. Holter ECG monitoring, which allows detecting myocardial hypoxia in the patient’s daily life, is considered to be an equally informative method for the painless form of coronary heart disease.
- Echo-KG – ultrasound examination of the heart, which allows to assess the condition and contractile activity of the myocardium, to study the valve apparatus;
- coronarography – a contrast medium is introduced using catheters alternately into the coronary arteries. A series of x-rays are taken, as a result of which all vasoconstrictions are visualized;
- CT-heart with intravenous contrasting – iodine-containing substance is injected into the peripheral vein during tomography, while all the vessels and cavities of the heart are visible;
- myocardial scintigraphy – is a radiological method. Cardiotropic radioactive isotopes are introduced into the body, the radiation from which is then recorded by a gamma-ray tomograph.
At the reception, the cardiologist carefully collects an anamnesis. It is important to establish the nature and duration of the pain syndrome, its relationship with physical activity and the possibility of stopping nitroglycerin preparations. During a physical examination (examination), the doctor discovers the accompanying symptoms of coronary artery disease:
- the presence of edema;
- wet wheezing when breathing;
- crepitus (crisp sound) in the lungs;
- an increase in liver size (hepatomegaly).
The final diagnosis of “coronary heart disease” is made on the basis of instrumental and laboratory examination methods:
- standard or transesophageal electrocardiography;
- blood tests for protein enzymes, sugar, cholesterol and other indicators;
- coronary angiography.
Pain in coronary heart disease
The cause of the pain is irritation of the nerve receptors of the heart with toxins formed in the heart muscle as a result of its hypoxia.
Pain in coronary heart disease is usually concentrated in the heart. As mentioned above, pain in most cases occurs during physical exertion, severe stress. If pains in the heart begin at rest, then with physical exertion they tend to intensify.
Pain is usually observed in the sternum. It can radiate to the left shoulder blade, shoulder, neck. The intensity of pain is individual for each patient. The duration of the attack is also individual and ranges from half a minute to 10 minutes. Taking nitroglycerin usually helps relieve a pain attack.
Men often have abdominal pain, which is why angina pectoris can be mistaken for some gastrointestinal disease. Also, pain with angina pectoris most often occurs in the morning.
Treatment of the disease
During my practice (and this is no less, 14 years), I managed to strengthen my opinion that convincing a patient to treat a disease that does not bother him is extremely difficult. Although it is precisely painless myocardial ischemia, which is considered prognostically unfavorable, needs timely adequate therapy. Indeed, in 40-46% of cases, it becomes the cause of sudden coronary death.
Prescribe medications should only be a qualified specialist, I independently recommend not to cancel or add any drugs.
Non-drug therapy of the disease consists in the correction of modifiable risk factors for its development. Namely, in a decrease in body weight, a decrease in the proportion of fatty foods in the diet, and refusal from smoking and drinking alcohol. Positive effect on microcirculation in the heart muscle and moderate physical activity.
Drug treatment of “mute” forms of ischemia is based on the basics of the treatment of coronary artery disease and is selected strictly individually, based on the patient’s age, premorbid background and examination results.
To improve myocardial blood supply, the following groups of drugs are used:
- β-blockers (“Atenolol”, “Bisoprolol”, “Concor”) – reduce the heart rate, thereby reducing the load on the heart;
- calcium antagonists (“Nifedipine”, “Amlodipine”, “Verapamil”) – dilate small vessels;
- antiplatelet agents (Aspirin-Cardio, Cardiomagnyl, Aspecard) – reduce blood viscosity;
- lipid-lowering (“Crestor”, “Rosuvastatin”, “Atorvastatin”) – affect the level of harmful lipoproteins of low and very low density, triglycerides and cholesterol;
- antiarrhythmic (“Amiodarone”, “Cordaron”, “Etatsizin”) – are prescribed for arrhythmias accompanying ischemia;
- ACE inhibitors (Captopril, Lisinopril, Enalapril) – regulate blood pressure;
- diuretics (Veroshpiron, Indapamide, Triampur) – remove fluid from the body, which puts an additional burden on the heart;
- prolonged nitrates (Isoket, Cardix, Efoxlong, Sydnopharm) have a vasorelaxating effect on coronary vessels.
If the narrowing of the vessels supplying the myocardium is too pronounced and conservative therapy is ineffective, then you have to resort to surgical methods of treating painless ischemia: endovascular stenting or coronary artery bypass grafting.
The first operation is minimally invasive and consists in maintaining a balloon inflated under x-ray control into the affected vessel. Then, on his meta, a metal stent is installed – a hollow cylinder, which will retain the initial lumen of the coronary artery. As a result of this intervention, normal blood flow in the myocardium resumes.
In case of critical occlusion of the vessel, coronary artery bypass grafting is performed, which consists in creating a “roundabout” of blood supply. That is, a “bridge” between the aorta and the normally functioning part of the coronary artery is constructed by a vascular autograft.
In my practice, there was one particularly indicative case of painless myocardial ischemia. A man was admitted to the admission department with a referral for hospitalization issued by a local therapist. Patient N., 54 years old, had absolutely no complaints. Got on a scheduled annual inspection from the place of work.
A history of alcohol abuse for 10 years. Overweight objectively attracted attention. On several ECGs performed at the clinic, a skew-down depression of the ST segment by 1-2 mm was recorded, which lasted no more than a minute. There were several such episodes on the cardiogram. The patient was hospitalized in the department with a preliminary diagnosis: “Painless myocardial ischemia.”
In the department, he underwent Holter monitoring of ECG, ECG with stress tests (treadmill), CT-heart with intravenous amplification, biochemical and clinical analysis of blood, urine. The changes revealed during the examination confirmed the previously diagnosed diagnosis.
The patient was prescribed Bisoprolol, Amlodipine, Sidnofarm, Cardiomagnyl, and Preductal. On subsequent ECGs, positive dynamics were noted. The patient was discharged seven days later with recommendations to continue taking the prescribed drugs, to exclude alcohol consumption and to come for a routine examination to the local therapist within a week.
Therapy of this pathology depends on its severity and form. A cardiologist individually selects ways to treat coronary heart disease, but there are general recommendations for all patients:
- Reduce the intensity of any physical activity. Gradually, they can be increased during the rehabilitation period.
- Bring back the weight.
- Limit salt and water intake.
- Adjust the menu. It is advisable to completely exclude products that contribute to the development of atherosclerosis – animal fats, smoked meats, fried foods, pickles, desserts.
- Stop drinking alcohol and smoking.
To stop the symptoms of coronary heart disease and restore myocardial function, a specialist is prescribed a course of drug treatment. If it, in combination with general measures, does not produce the expected therapeutic effect, surgical intervention is recommended:
- coronary artery bypass grafting (myocardial revascularization);
- balloon angioplasty;
- coronary artery vasodilation (balloon dilatation).
Conservative therapy is developed separately for each patient’s cardiologist, but there is a standard scheme “ABC”, which involves a combination of 3 groups of medicines:
- antiplatelet agents – Thrombopol, Aspirin, Clopidogrel, Acekardol;
- beta-blockers – Niperten, Egilok, Dilatrend, Concor;
- statins and fibrates – Simvastatin, Lovastatin, Atorvastatin, Fenofibrat.
In the presence of concomitant pathological signs, additional drugs are prescribed. Coronary disease – treatment:
- anticoagulants – Heparin, Fenilin;
- nitrates – isosorbide mononitrate, Nitroglycerin;
- diuretics – Lasix, Furosemide;
- lipid-lowering drugs – Polycosanol, Nolipid;
- antiarrhythmic drugs – Amiodarone, Cordaron;
- angiotensin converting enzyme inhibitors – Captopril, Enalapril;
- metabolic cytoprotectors – Mexico, Coronater.
The use of alternative medicine techniques is allowed only with the permission of the endocrinologist as symptomatic therapy. With their help, ischemic disease is alleviated – folk remedies reduce high blood pressure, accelerate the elimination of excess fluid from the body and improve metabolism. They cannot normalize myocardial function and prevent its necrosis.
The treatment of coronary heart disease is a long and complex process, in which sometimes the leading role is played not so much by the art and knowledge of the attending physician as by the patient’s desire to cope with the disease. In this case, it is necessary to be prepared for the fact that a complete cure for coronary heart disease is usually impossible, since the processes in the vessels of the heart in most cases are irreversible.
Treatment in the first stage of the disease usually involves only conservative methods. They are divided into drug and non-drug. Currently, in medicine, the most considered is the treatment regimen of the disease, called A-B-C. It includes three main components:
- antiplatelet agents and anticoagulants,
- beta blockers,
What are these classes of drugs for? Antiplatelet agents prevent platelet aggregation, thereby reducing the likelihood of intravascular thrombus formation. The most effective antiplatelet agent with the greatest evidence base is acetylsalicylic acid. This is the very Aspirin that our grandfathers and grandmothers used to treat colds and flu.
However, conventional Aspirin tablets are not suitable as a continuous drug in case of coronary heart disease. The thing is that taking acetylsalicylic acid carries the risk of irritation of the stomach, the occurrence of peptic ulcer and intragastric bleeding.
Anticoagulants also prevent blood clots, but have a completely different mechanism of action than antiplatelet agents. The most common drug of this type is heparin.
Beta-blockers block the effects of adrenaline on specific receptors located in the heart – beta-type adrenaline receptors. As a result, the patient’s heart rate decreases, the load on the heart muscle, and as a result, its oxygen demand. Examples of modern beta-blockers are metoprolol, propranolol.
What is the risk of coronary heart disease?
The pathology considered is chronic and is constantly progressing, causing irreversible myocardial damage and dangerous consequences. If coronary heart disease has developed, complications may include:
- lack of energy metabolism;
- disorders of automatism, conduction and excitability of the myocardium;
- violation of systolic and diastolic muscle functions;
- deterioration of contractility of the left ventricle (“stunned myocardium”).
Complicated coronary heart disease in most cases leads to a steady decrease in the intensity of coronary circulation. In combination with the above morphofunctional changes and progressive atherosclerosis of the arteries, this results in chronic heart failure. This disease is often the cause of early death, especially of mature men.
Many people suffering from ischemic heart disease become accustomed to their disease and do not perceive it as a threat. But this is a frivolous approach, because the disease is extremely dangerous and, without proper treatment, can lead to a grave consequence.
The most insidious complication of coronary heart disease is a condition that doctors call sudden coronary death. In other words, it is cardiac arrest caused by electrical instability of the myocardium, which, in turn, develops against the background of IHD. Very often, sudden coronary death occurs with patients with latent coronary artery disease. In such patients, often the symptoms are either completely absent or not taken seriously.
Another way of developing coronary heart disease is myocardial infarction. With this disease, the blood supply to a certain part of the heart deteriorates so much that its necrosis occurs. The muscle tissue of the affected area of the heart dies, and scar tissue appears in its place. This happens, of course, only if the heart attack does not lead to death.
A heart attack and coronary heart disease in itself can lead to another complication, namely, chronic heart failure. This is the name of a condition in which the heart does not properly perform its blood pumping functions. And this, in turn, leads to diseases of other organs and violations of their work.
To prevent the development of the described pathology, it is necessary to take measures to maintain blood circulation in a normal condition and prevent atherosclerosis.
It is well known that treatment is always more difficult than avoiding the disease. This is especially true for such a serious and sometimes incurable ailment as ischemic heart disease. Millions of people around the world and in our country suffer from this heart disease. But in most cases, the occurrence of the disease is not to blame for an unfavorable combination of circumstances, hereditary or external factors, but the person himself, his wrong lifestyle and behavior.
Recall again the factors that often lead to an early incidence of coronary heart disease:
- sedentary lifestyle;
- a diet containing a large amount of bad cholesterol and simple carbohydrates;
- constant stress and fatigue;
- uncontrolled hypertension and diabetes;
To change something on this list, making sure that this problem goes away from our lives and we would not have to be treated for coronary artery disease, most of us can do it.
How is coronary heart disease
Above, we indicated which symptoms accompany coronary heart disease. Here we raise the question of how to determine whether a person has atherosclerotic changes in the vessels in the early stages, even at a time when obvious evidence of coronary artery disease is not always observed. Moreover, such a sign as pain in the heart is not always indicative of coronary heart disease. Often it is caused by other causes, for example, diseases associated with the nervous system, spine, various infections.
An examination of a patient complaining of negative phenomena typical of coronary heart disease begins with listening to his heart sounds. Sometimes the disease is accompanied by noise typical of IHD. However, often this method fails to identify any pathology.
The most common method of instrumental research of heart activity is a cardiogram. With its help, you can track the distribution of nerve signals in the heart muscle and how its departments are reduced. Very often, the presence of coronary heart disease is reflected in the form of changes on the ECG. However, this does not always happen, especially in the early stages of the disease.
Therefore, a cardiogram with a stress test is much more informative. It is carried out in such a way that during the removal of the cardiogram, the patient is engaged in some kind of physical exercise. In this state, all pathological abnormalities in the work of the heart muscle become visible. After all, during physical exertion, the heart muscle begins to lack oxygen, and it begins to work intermittently.
Sometimes the method of daily Holter monitoring is used. With it, the cardiogram is removed for a long period of time, usually during the day. This allows you to notice individual deviations in the work of the heart, which may not be present on a regular cardiogram. Holter monitoring is carried out using a special portable cardiograph, which a person constantly carries in a special bag. At the same time, the doctor attaches electrodes to the human chest, exactly the same as with a normal cardiogram.
Also very informative is the echocardiogram method – ultrasound of the heart muscle. Using an echocardiogram, a doctor can evaluate the performance of the heart muscle, the size of its departments, and blood flow parameters.
In addition, informative in the diagnosis of coronary heart disease are:
- general blood analysis,
- blood chemistry,
- blood glucose test
- blood pressure measurement
- selective coronography with contrast medium
- CT scan,
Many of these methods make it possible to identify not only the IHD itself, but also the concomitant diseases that aggravate the course of the disease, such as diabetes mellitus, hypertension, blood and kidney diseases.
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