Left ventricular hypertrophy diagnosis and treatment symptoms

Treatment of hypertrophy of the left heart is to affect the cause of the development of pathology. The treatment of altered myocardial tissues should be under the supervision of the attending physician. The main task is to reduce the size of the left ventricle to a normal volume.

First of all, you need to abandon addictions. Reduce salt intake, exclude fatty and fried foods from the daily diet.

If drug therapy did not give the expected results, then surgical treatment is used. The following surgical interventions are indicated:

  • Morrow operation, which is a fragmented myocardial removal in the septum between the ventricles;
  • replacement or transplantation of the aortic valve;
  • mitral valve replacement;
  • installation of a stent in the lumen of the coronary vessels;
  • separation of adhesions at the mouth of the main artery.

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Heart valve replacement

When the treatment for hypertrophy of the left heart does not bring the expected results, an pacemaker is introduced. This is a device designed to restore normal heart rate.

In general, for each patient, the treatment of the pathology under consideration is selected individually. All existing disorders of the heart, general condition and the presence of concomitant abnormalities are taken into account.

It is worth noting that timely detected hypertrophy is easier to correct. If the disease is not treated in the early stages, serious complications can arise, therefore, at the slightest manifestation of hypertrophy, it is necessary to seek the help of a cardiologist. The specialist will prescribe an adequate and competent therapy tactic that gives chances for a long life.

Many patients are interested in what it is – concentric hypertrophy of the left ventricle, since it is important to determine the peculiarity of the course of the disorder and its manifestation for timely treatment. An intense load on the heart occurs with prolonged negative exposure to high blood pressure.

With the occurrence of such a pathology, the heart muscle functions practically for wear. Thickening and enlargement of the walls of the myocardium cannot last very long, since as the disease progresses there is a high risk of acute ischemia. In addition, pathology can lead to sudden cardiac death.

In order to conduct treatment and reduce the risk of dangerous complications, you must understand what it is – concentric hypertrophy of the left ventricle, and how dangerous it is to life.

Treatment of concentric left ventricular myocardial hypertrophy must be timely and comprehensive and takes a lot of time. Therapy is aimed at eliminating the main causes that provoked such a pathology, and involves adjusting the pressure to restore normal values ​​with the constant use of antihypertensive drugs. With high vascular resistance, therapy is aimed at eliminating the existing pathology with the help of medications.

Treatment is to slow the development of the disorder. This can be achieved by organizing a healthy lifestyle, which implies the normalization of nutrition, adherence to the daily regimen. Consumed foods must be rich in polyunsaturated fats, since the latter help reduce the risk of atherosclerosis. The food should contain vitamins and minerals necessary for the body.

In addition, you need to devote enough time to sleep and rest, moderate exercise. If there is obesity, then you should definitely reduce weight, since this deviation is one of the causes of the development of the disease. Of the physical activities, it is best to give preference to aerobics or swimming. In any case, you can engage in sports after consulting a doctor. Refusal of existing bad habits has a positive effect on the whole body.

For treatment, medication is necessarily used. A person should take medicine throughout his life – the only way to achieve normalization of health. Cardiologists often prescribe antiarrhythmic drugs and beta-blockers.

If all these measures do not bring the required result, then doctors can recommend surgery. Surgical intervention involves the removal of a hypertrophied region of the heart muscle. Such an operation is very complicated, therefore it is used in the most exceptional cases.

What is a disease?

Under the left ventricular myocardial hypertrophy is understood an abnormal state of the heart, which is characterized by an increase in the mass of the heart muscle. Often, the pathology is detected by chance during an ECG or ultrasound.

For a long time, it can be asymptomatic, and portend serious heart disease. Without proper and adequate treatment, this condition often leads to an increased risk of heart attacks or strokes, which ultimately leads to death.

The muscle cells of the heart, called cardiomyocytes, lack the ability to divide, the development of myocardial hypertrophy occurs due to an increase in the number of intracellular structures and the volume of the cytoplasm. The consequence of this is a change in the size of the cells of the heart muscle, and an increase in myocardial mass.

The pathology under consideration is an adaptive process, that is, it develops in response to all kinds of disturbances that impede the normal activity of the myocardium. Such conditions force the heart muscle to contract with an increased load.

Which contributes to the strengthening of metabolic processes, the growth of cell mass and tissue volume in the myocardium.

At an early stage of its development, the analyzed LV disease is adaptive, and normal blood circulation is maintained by the heart by increasing the mass of this organ. But over time, inhibition of myocardial function occurs, and hypertrophy is replaced by atrophy, which, in turn, is the opposite phenomenon. That is, there is a decrease in cells in size.

Myocardial hypertrophy of the left ventricle of the heart is formed not only in various diseases, but also in absolutely healthy people with intense stress. Most athletes who engage in heavy physical work suffer from this disease.

There are many examples when such a pathology flowed into heart failure. Excessive physical activity leads to dangerous consequences, engaging in this kind of activity, due attention should be paid to the state of the heart muscle in order to avoid serious complications.

Illness in a child

In childhood, concentric hypertrophy of the left ventricle of the heart can be an acquired or congenital form of pathology. The acquired form of the disease is mainly due to carditis, heart defects, pulmonary hypertension. Symptoms of pathology in a child can be very different. A newborn baby becomes restless and noisy, or vice versa – lethargic, refuses to feed.

An older child is able to accurately indicate the nature of the complaints. He is worried about heart pain, lethargy, pallor, fatigue, shortness of breath. The tactician for the treatment of concentric hypertrophy of the left ventricle is selected by the cardiologist after the examination.

Varieties of pathology

The proliferation of muscle cells in the heart can cover the entire chamber or be located in various places. In most cases, it is localized on the septum between the ventricles, the aortic opening and the transition of the atrium to the left ventricle. At the location where an increase in muscle mass was formed, the following types of abnormal conditions are noted:

  • Concentric left ventricular myocardial hypertrophy (it is also symmetrical) leads to a uniform thickening of the heart muscle. So that the ventricle can push blood into the opening of the main artery, the layer of its musculature progressively grows.
  • Eccentric hypertrophy is formed mainly on the interventricular septum, in some cases, the side wall or in the apex is affected.

Depending on the effect on systemic circulation, the anomaly is divided into:

  • Without obstruction of blood flow in the outflow tract. In such a situation, the effect on systemic circulation will be minimal. Often, the concentric form is not accompanied by obstruction, in contrast to the asymmetric variety.
  • With obstruction. With a contraction of the ventricle, aortic orifice is compressed. Along with this, there is an additional barrier to normal blood flow, which increases hypertrophy to a greater extent.

Classification by muscle wall thickness:

  • moderate hypertrophy is observed with a thickening of the heart muscle of more than 11 mm, but less than 21 mm;
  • for an average degree, the thickness of the myocardium is 21–25 mm;
  • pronounced LV pathology is characterized by a thickening of the muscle at the time of heart contraction of more than 25 mm.

Moderate changes in the myocardium of the left ventricle do not pose a threat to life. Often observed in people involved in physical labor or sports, performing an intense load.

Causes

These reasons determine the development of acquired hypertrophy of the left ventricle of the heart. In addition, there are a number of anomalies, congenital and inherited, due to which there is an increase in the muscle layer in the left ventricle:

  • mutations in the genes responsible for the synthesis of heart proteins;
  • reduced aortic diameter;
  • infection or absence of the pulmonary artery;
  • defect of interventricular septum;
  • congenital stenosis of the aortic valve;
  • mitral insufficiency.

The considered change in the heart muscle is for the most part a concomitant syndrome of various chronic heart diseases. The causes of LV hypertrophy are partly related to genetic defects, which means that the anomaly is inherited. The main causes of myocardial changes include:

  • addiction;
  • obesity;
  • aortic valve stenosis;
  • chronic stress;
  • diabetes;
  • prolonged intense physical activity;
  • hypertonic cardiopathy;
  • essential arterial hypertension.
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Often, the pathological condition of the heart occurs against the background of arterial hypertension. In most cases, an increase in myocardium in volume is due to exposure to high blood pressure.

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Overweight is also a factor provoking the formation of cardiac pathology. An enlarged body needs a more intense blood supply, therefore abnormal changes in the heart muscle are formed.

Heart defects that impede the outflow of blood from the ventricle are a congenital predisposition to the formation of pathological changes in the myocardium. It is with genetic defects of the heart muscle that LV hypertrophy in a child is associated.

Quite often, concentric hypertrophy of the left ventricle occurs in the presence of a genetic predisposition. The situation may worsen with obesity and high blood pressure. Quite often, a disease develops for reasons such as:

  • damage to the mitral valve;
  • arterial stenosis;
  • excess weight;
  • high pressure;
  • hypertrophic cardiomyopathy;
  • stress;
  • pulmonary diseases.

The mitral valve regulates blood circulation in the chambers of the heart muscle. If its functioning is disturbed, hypertrophy may develop. Among other reasons, it is necessary to highlight excess weight, which leads to the development of numerous disorders in the body, including the occurrence of cardiovascular pathologies.

Often expressed concentric hypertrophy of the left ventricle develops due to arterial hypertension. Often other disorders also join this condition, which are clearly visible when conducting an electrocardiogram.

The formation of minor concentric left ventricular myocardial hypertrophy is considered the norm in people who have been professionally involved in sports for a long time. With constant training, the load on the heart is quite strong and constant. As a result, the walls of the left ventricle become somewhat thicker.

Despite the fact that this is considered the norm, it is important not to miss the moment when moderate concentric hypertrophy of the left ventricle passes into a more complex form. In this regard, athletes are constantly under the supervision of doctors who know for sure in which sport this condition is permissible, and in which it should not be.

Another reason for the formation of such a pathology is ischemia. In this case, the myocardium experiences a periodic or constant lack of oxygen. Muscle cells without the additional supply of energy substrates do not work as efficiently as they should be normal. Therefore, the remaining cells have to function with a much greater load. Gradually, a thickening of the heart muscle occurs.

Clinical symptoms

Signs of hypertrophy of the left heart are not always observed. A person may not even suspect the presence of such a problem. Improper development of the fetus during pregnancy often leads to the formation of defects and hypertrophy of a characteristic organ.

Such cases should be observed from birth to avoid severe complications.

Typical symptoms of this anomaly are:

  • high level of pressure, poorly amenable to medical correction;
  • interruptions in cardiac activity;
  • shortness of breath, periodic attacks of suffocation, causeless intense cough in a supine position;
  • fainting conditions;
  • repeated pain attacks in the heart and behind the sternum;
  • pressure instability;
  • headaches of an obscure nature, drowsiness, general weakness;
  • sleep disturbance;
  • swelling of the face and limbs in the evening;
  • blue nasolabial triangle and nail plate.

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Even with minor symptoms of the analyzed problem and deterioration of well-being, you should immediately seek medical help for further diagnosis and therapy.

For a long time, left ventricular myocardial hypertrophy can not be felt, since the muscle can compensate for the defect in the initial period of growth of cardiomyocytes, when blood circulation is not yet disturbed. Alarming signs that can not be ignored and which may be the first symptoms of thickening of heart tissue:

  • respiratory failure, shortness of breath;
  • fatigue against the background of previous physical activity;
  • periodically occurring pains in the region of the heart, especially after physical exertion (compressive, pressing, burning);
  • frequent dizziness;
  • the appearance of fainting conditions;
  • feeling of a sinking heart;
  • blood pressure surges;
  • swelling of the legs.

One of the first studies that patients with suspected hypertrophy is referred to is cardiac electrocardiography. This procedure helps to establish the cause of the deviation, to identify the risk of heart failure. In patients who are examined with a preliminary diagnosis of left ventricular hypertrophy, the sinus rhythm of the heart is impaired, and in order to check this, it is additionally recommended to conduct daily ECG monitoring. When decoding a cardiogram, among the signs indicating a likely thickening of the walls of the left ventricle, there are:

  • left-side deviation of the electrical axis of the heart;
  • increase in the amplitude and duration of the QRS complex
  • changing the shape and direction of the ST segment and the T wave and others.

The diagnosis cannot be based only on ECG indices, therefore echocardiography is mandatory to detect the presence of hypertrophy, its degree and effect on blood flow. With pathology, the following symptoms are noted:

  • thickening of the heart wall – for women more than 1 cm, for men – more than 1,1 cm;
  • relative wall thickness index is more than 0,42;
  • the ratio of myocardial mass to body mass – for men more than 125 g/cm2, for women – more than 95 g/cm2.

With left ventricular hypertrophy of a concentric type, the symptoms may vary slightly. Sometimes for a long time the signs of the violation are completely absent, and the patient is not aware of the presence of pathology until it is detected during the diagnosis. The asymptomatic course of the disease can last several years in a row.

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Recognizing concentric hypertrophy of the left ventricle is possible by the presence of angina pectoris, which often develops against the background of ongoing changes in the heart muscle and its functionality. The heart thus greatly increases in size, since a greater supply of oxygen is required.

In some cases, atrial fibrillation develops, characterized by atrial fibrillation and myocardial oxygen starvation. Often, the patient is faced with a condition in which there is literally a sinking heart, as well as a cardiac arrest. The disease in all cases is accompanied by severe shortness of breath, which can worsen even with minor exertion. In addition, among the main symptoms of concentric hypertrophy of the walls of the left ventricle, it is necessary to distinguish such as:

  • headache;
  • arrhythmia;
  • pressure instability;
  • heartache;
  • insomnia;
  • discomfort in the chest area.

Such a disease often leads to heart failure and myocardial infarction. If dangerous symptoms occur, you should immediately consult a doctor. If there is a predisposition to the development of such a pathology, a comprehensive diagnosis is required annually.

Problem diagnosis

First of all, diagnostic measures are aimed at detecting diseases of the circulatory system. Only the attending specialist can make a correct diagnosis, so he collects the patient’s history (information about the presence of hereditary diseases, patient complaints).

The presence of endocrine diseases and congenital malformations in the family increases the likelihood of developing hypertrophy of the left heart. For a more complete diagnosis, the doctor prescribes the following procedures:

  • laboratory blood tests (general and biochemical), study of hormonal status, urinalysis;
  • electrocardiogram;
  • X-ray examination of the chest organs, which determines the increase in the shadow of the heart and the shadow of the aorta;
  • daily monitoring of ECG;
  • Ultrasound of the heart before and after exercise;
  • CT and MRI for more accurate determination of heart disease and associated abnormal changes;
  • Echocardiography.

In some cases, coronography is prescribed to assess coronary artery patency.

To determine the presence of concentric type left ventricular myocardial hypertrophy, the doctor initially collects a history of the course of the disease, evaluates the patient’s complaints, and also finds out information about the presence of heart pathology in close relatives. To clarify the diagnosis, such procedures are prescribed as:

  • electrocardiogram;
  • echocardiography;
  • daily monitoring and ECG;
  • X-ray
  • Doppler test;
  • blood test;
  • Analysis of urine.

To determine the extent of the disease, the doctor prescribes coronary angiography. A similar technique is an X-ray study with the introduction of a contrast medium into the cardiac bloodstream. For better visualization of intracardiac pathology, MRI of the heart muscle is prescribed.

The echocardiographic criteria for concentric hypertrophy of the left ventricle is the mass of the myocardium, or rather its index. A similar technique allows you to measure the thickness of the myocardial wall on different segments of the heart muscle. Echocardiographic criteria for concentric hypertrophy of the left ventricle is the relative thickness of the myocardial wall. The normal structure is characterized by the fact that the OTC is less than 0,45, and the index is within normal limits.

Medication Therapy

The basis of treatment is the elimination of the provoking factor that led to the development of hypertrophy. Therapeutic measures necessarily include the use of medications that help normalize blood pressure, eliminate endocrine and metabolic disorders.

In order to reduce heart rate and eliminate oxygen starvation of cells, beta-blockers are prescribed. They help prevent even greater progression of angina pectoris and provide a reduction in the frequency of painful symptoms. Angiotensin-converting enzyme inhibitors provide protection to affected cells and help prevent their secondary damage.

To reduce the amount of calcium in the cells of the heart muscle, calcium antagonists are prescribed. They prevent the formation of various intracellular structures that can provoke the development of hypertrophy. Given the available signs of such a pathological condition, the following drugs are prescribed:

  • antiarrhythmic;
  • cardiac glycosides;
  • diuretic;
  • antioxidants.

It is worth noting that minor concentric hypertrophy of the left ventricle is completely life-threatening and does not require special treatment, but monitoring the patient is required.

Folk remedies

Folk remedies can be used as adjunctive therapy to the main treatment. You can use them only after a diagnosis and with the permission of a doctor. Alternative treatment implies the use of medicinal herbs, which help to get rid of the cause of the disease, its symptoms and are aimed at normalizing well-being.

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To prepare the broth, you will need a mixture of rosemary, motherwort, dried cinnamon and kidney tea. All components must be mixed in equal proportions, then take 2 tbsp. l mixture and pour 300 ml of boiling water. Boil over low heat, cool, strain and take 3 times a day.

A strong infusion of St. John’s wort will help strengthen the heart muscle. Before consuming it, you need to add a little honey. Strawberry jam with milk, dried fruits, dried apricots, cranberries with sugar, raisins have a good effect.

Surgical intervention

If drug therapy did not bring the desired result, then surgical procedures may be prescribed for the treatment. The following types of intervention are indicated:

  • mitral valve replacement;
  • Morrow operation;
  • commissurotomy;
  • replacement or transplantation of the aortic valve;
  • coronary stenting.

Stenting is prescribed in case of myocardial ischemia. With aortic stenosis, adhesions are dissected on the valves. A similar technique allows you to slightly reduce the resistance that the ventricular myocardium encounters when blood flows into the aorta. If the therapy does not bring the expected result, then a cardiovert-defibrillator or pacemaker is sewn. These devices are designed to restore the correct rhythm of the heart.

Possible complications

Moderate hypertrophy is usually harmless. This is a kind of compensatory reaction of the body, designed to normalize the blood supply to tissues and organs. For a long time, a person may not notice the presence of hypertrophy, since it does not manifest itself in any way. As the pathology progresses, the following may develop:

  • ischemia, myocardial infarction;
  • chronic cerebrovascular accident;
  • severe arrhythmia;
  • stroke;
  • sudden cardiac arrest.

Angina pectoris occurs due to an increase in the size of the myocardium of the heart, and basically it happens rather unevenly. Coronary vessels are compressed. Angina pectoris is characterized by the presence of sternal pain of a pressing or compressive nature. In addition, the disease proceeds against the background of high blood pressure and a significant increase in heart rate.

Another dangerous complication is thrombosis. Due to insufficient blood pumping, blood clots form on the walls of the heart chamber and valves. They arise as a result of damage to the walls and subsequent sedimentation of red blood cells on them. Such a complication is very dangerous in that the thrombus can break off from its attachment site and clog the vessel.

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If hypertrophy proceeds for a long time, then it can eventually become chronic. In this case, swelling is formed throughout the body. Patients cannot move normally due to severe dyspnea, poorly tolerate any load. In the later stages, a person is not even able to leave the house.

Forecast

If moderate and minor hypertrophy of the left ventricle of the heart is diagnosed, the prognosis is favorable during treatment and regular medical supervision: patients remain able-bodied, quality of life is not impaired, pregnancy and childbirth are not excluded for women. A severe degree of pathology can lead to disability, mortality is 4-5%.

The prognosis of the course of the disease is determined by the root cause of such a violation. At the initial stages of hypertrophy, which is corrected with antihypertensive drugs, the prognosis is quite good. The chronic form develops very slowly, and a person with such a disease can live for several decades. Moreover, the quality of his life does not suffer.

In older people with myocardial ischemia, as well as previously suffered heart attacks, the development of the chronic stage is difficult to predict. It can develop both slowly and rapidly, which leads to disability and loss of human performance.

Left ventricular hypertrophy – what does it mean?

To understand the essence of the problem and the causes of its occurrence, we first turn to anatomy and physiology. The left ventricle is one of the four heart chambers from which a large circle of blood circulation originates. Due to contractions of the left ventricle, the bulk of the blood is pumped to the brain, other organs, limbs and nourishing the heart itself. The greatest responsibility and load is assigned to this camera, therefore it begins to suffer first in case of various malfunctions.

Hypertrophy is a thickening of the walls of the heart in response to an increase in the load on the myocardium under the influence of various factors, and in the region of the left ventricle this phenomenon is observed in most cases. Adapting to new, complicated conditions, cardiac muscle cells (cardiomyocytes) begin to grow, while the walls of the left ventricle become denser, lose their elasticity and become thicker.

The inner space of the chamber remains unchanged, but the septum between the right and left ventricles can also expand (evenly or unevenly), which can cause a violation of the mitral and aortic valves. Due to pathological processes, the vessels supplying the myocardium are compressed, which in the current conditions needs a greater supply of oxygen and nutrients.

What is the danger of hypertrophy of the left ventricle of the heart?

When hypertrophy of the left ventricle of the heart develops, organ nutrition is disturbed, and zones of abnormal hyperactivity and bypass conduction are formed. As a result of this, arrhythmia is observed, and due to an increase in the volume of the heart muscle and impaired blood flow in the vessels, ischemia and tissue necrosis occur. Moreover, if, for other reasons, oxygen deficiency is felt, the situation is exacerbated.

Hypertrophy of the left ventricle of the heart can have critical consequences when there is a sharp intense load on the myocardium, especially for inactive people and those who smoke, drink alcohol. The risk of coronary heart disease, myocardial infarction, congestive heart failure, cerebral stroke, sudden cardiac arrest is high.

Left ventricular hypertrophy of the heart – what to do?

If hypertrophy of the left ventricle of the heart is detected, treatment should be prescribed in accordance with the cause that provoked this violation. The main goal of treatment is the normalization of myocardial function and the prevention of complications, which is achieved mainly by medical or surgical methods. In addition, the complex treatment includes:

  • normalization of lifestyle, rest and sleep;
  • rejection of bad habits;
  • adherence to a rational diet;
  • body weight control;
  • dosing of physical activity;
  • correction of hormonal imbalance;
  • elimination of stressful situations.

Patients who have been given a disappointing diagnosis are alarmed if left ventricular hypertrophy is being treated and whether complete healing is possible. It is impossible to reduce the thickness of the myocardium and completely restore its functioning using the currently existing methods, however, with timely treatment started, good results are achieved, and patients can live a full life for many years.

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We list which drugs for hypertrophy of the left ventricle of the heart are prescribed in most cases:

  1. Calcium channel blockers (Verapamil, Diltiazem, Procardia, Cardizem) – reduce myocardial contractility, relax the tissue of the walls of blood vessels, and reduce blood pressure.
  2. Beta-blockers (Concor, Bisoprolol, Carvedilol, Betalok) – reduce heart rate, lower blood pressure, prevent some harmful effects of stress hormones.
  3. Antihypertensive drugs, especially from the group of angiotensin-converting enzyme inhibitors (Ramipril, Enalapril, Captopril, Lisinopril) – to lower blood pressure, reduce the load on the myocardium and improve blood flow.
  4. Metabolic cardiac drugs (Cardonate, Preductal, Inosine) – to improve the nutrition of the heart muscle, normalize metabolic processes in it, increase tissue resistance to ischemia.
  5. Antiarrhythmic medicines (Disopyramide, Amiodarone, Quinidine) – in the presence of complications in the form of a heart rhythm disorder.
  6. Nitroglycerin preparations – for the expansion of coronary vessels.

Depending on the severity of the patient’s condition, treatment can be carried out on an outpatient basis or in a hospital setting. If drug therapy does not bring positive results, they resort to surgical treatment, which is also indicated for congenital heart defects that cause myocardial hypertrophy. So, surgery can be performed on the valve apparatus, the elimination of stenosis, antiarrhythmic surgical interventions.

Having received the doctor’s recommendations on how to treat left ventricular hypertrophy of the heart, with his permission, therapy can be supplemented with alternative methods, most of which are aimed at eliminating hypertension. If hypertrophy of the left ventricle of the heart is associated with high blood pressure, taking a decoction will help.

When a thickening of the walls of the left ventricle of the heart is fixed, it is very important to pay attention to nutrition. Servings should be small, the number of meals – 5-6 per day. You should reduce the use of salt, flour products, sweets, fatty dishes. It is necessary to completely abandon pickles, smoked foods, fried foods, and too spicy dishes. Useful vegetables, fruits, seafood, dairy products. In addition, an adequate drinking regimen must be observed.

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Svetlana Borszavich

General practitioner, cardiologist, with active work in therapy, gastroenterology, cardiology, rheumatology, immunology with allergology.
Fluent in general clinical methods for the diagnosis and treatment of heart disease, as well as electrocardiography, echocardiography, monitoring of cholera on an ECG and daily monitoring of blood pressure.
The treatment complex developed by the author significantly helps with cerebrovascular injuries and metabolic disorders in the brain and vascular diseases: hypertension and complications caused by diabetes.
The author is a member of the European Society of Therapists, a regular participant in scientific conferences and congresses in the field of cardiology and general medicine. She has repeatedly participated in a research program at a private university in Japan in the field of reconstructive medicine.

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