The leading cause of disability and mortality worldwide are diseases of the cardiovascular system. According to medical and scientific data, 1.2 million people die annually in Russia, 35% of whom are diagnosed with ischemic heart disease (IHD). The situation can be corrected if people know more about the disease.
Causes of CHD
Insufficient blood supply to the heart muscle is a major cause of coronary artery disease. It does not pass through the coronary arteries of the heart in the required quantity due to their blockage or narrowing. Depending on the severity of cardiac "starvation," there are several forms of coronary disease. 98% of clinical cases are associated with atherosclerosis of the coronary vessels. Other causes of CHD include:
- thromboembolism, which develops on the background of atherosclerotic lesions,
- hyperlipidemia and alpha-lipoprotein reduction,
- stable exertional angina,
- high cholesterol
Forms of ischemic disease
Classification of coronary artery disease (ICD-10, 1992.)
- Angina pectoris
- - Stable exertional angina
- - Unstable Angina
- Primary myocardial infarction
- Repeated myocardial infarction
- Old (previously transferred) myocardial infarction (post-infarction cardiosclerosis)
- Sudden cardiac (arrhythmic) death
- Heart failure (myocardial damage due to coronary artery disease)
The main reason for the disruption of oxygen supply to the myocardium is the discrepancy between the coronary blood flow and the metabolic needs of the heart muscle. This may be due to:
- - Atherosclerosis of the coronary arteries with a narrowing of their lumen by more than 70%.
- - Spasm of unchanged (low) coronary arteries.
- - Violations of microcirculation in the myocardium.
- - Increased activity of the blood coagulation system (or a decrease in the activity of the anticoagulant system).
The main etiological factor in the development of coronary heart disease is atherosclerosis of the coronary arteries. Atherosclerosis develops consistently, in waves and steadily. As a result of the accumulation of cholesterol, an atherosclerotic plaque is formed in the artery wall. Excess cholesterol leads to an increase in the size of the plaque, and there are obstructions in the blood flow. Subsequently, under the influence of systemic adverse factors, the transformation of the plaque from stable to unstable occurs (cracks and tears occur). The mechanism of platelet activation and the formation of blood clots on the surface of an unstable plaque starts. Symptoms are exacerbated by the growth of an atherosclerotic plaque that gradually narrows the lumen of the artery. A decrease in the arterial lumen area of more than 90-95% is critical, causing a decrease in coronary blood flow and a deterioration in well-being even at rest.
Risk factors for coronary heart disease:
- Gender (male)
- Age> 40-50 years
- Smoking (10 or more cigarettes per day for the past 5 years)
- Hyperlipidemia (total plasma cholesterol> 240 mg / dl, LDL cholesterol> 160 mg / dl)
The clinical picture of CHD
The first description of stenocardia was suggested by an English doctor, William Geberden in 1772: “. chest pain that occurs during walking and causes the patient to stop, especially while walking soon after eating. It seems that this pain in the event of its continuation or enhancement can deprive a person of life, at the time of stopping all unpleasant sensations disappear. After the pain continues to occur for several months, it ceases to pass immediately when it stops, and in the future it will continue to occur not only when the person goes, but also when it lies ... ”Usually, the symptoms of the disease first appear after 50 years. In the beginning arise only during physical exertion.
The classic manifestations of coronary heart disease are:
- - Sternum pain, often radiating to the lower jaw, neck, left shoulder, forearm, hand, back.
- - The pain is pressing, squeezing, burning, choking. The intensity is different.
- - Provoked by physical or emotional factors. At rest, stop on their own.
- - Lasts from 30 seconds to 5-15 minutes.
- - Fast effect from nitroglycerin.
Treatment of Ischemic Heart Disease
Treatment is aimed at restoring the normal blood supply to the myocardium and improving the quality of life of patients. Unfortunately, purely therapeutic treatments are not always effective. There are many surgical correction methods, such as: aorto-coronary bypass, trans-myocardial laser myocardial revascularization and percutaneous coronary interventional procedures (balloon angioplasty, coronary artery stenting).
Selective coronary angiography is considered the “gold standard” in the diagnosis of obstructive lesions of the coronary arteries of the heart. It is used to find out whether the vessel has narrowed, what arteries are and how many of them are affected, in which place and in what extent. Recently, multispiral computed tomography (MSCT) with intravenous bolus contrasting has become increasingly common. In contrast to selective coronary angiography, which is essentially an X-ray surgical intervention on the arterial bed, and is performed only in a hospital, MSCT of the coronary arteries is usually performed on an outpatient basis by intravenous administration of a contrast agent. Another fundamental difference may be that selective coronary angiography shows the lumen of the vessel, and MSCT and the lumen of the vessel, and, in fact, the wall of the vessel in which the pathological process is localized.
Depending on the changes in the coronary vessels identified during coronary angiography, various methods of treatment can be offered:
Coronary artery bypass surgery - an operation that has been worked out for many years, during which a patient's own vessel is taken and hemmed to the coronary artery. Thus, a path is created to bypass the affected area of the artery. Blood in the normal volume enters the myocardium, which leads to the elimination of ischemia and the disappearance of strokes. CABG is the method of choice for a number of pathological conditions, such as diabetes mellitus, affection of the trunk, a multi-vascular lesion, etc. The operation can be performed with artificial blood circulation and cardioplegia, on a working heart without an artificial circulation, and on a working heart with an artificial circulation. As shunts can be used as the veins and arteries of the patient. The final decision on the choice of a particular type of operation depends on the specific situation and equipment of the clinic.
The balloon angioplasty, which was popular in its time, has lost its relevance. The main problem is the short-term effect of the performed x-ray surgical intervention.
A more reliable and, at the same time, minimally invasive method of restoring and maintaining the normal lumen of the vessel is stenting. The method is essentially the same as balloon angioplasty, but a stent is mounted on the cartridge (a small transformable metal mesh framework). When introduced into the site of constriction, the balloon with the stent is inflated to the normal vessel diameter, the stent is pressed against the walls and retains its shape constantly, leaving the lumen open. After the stent is inserted, the patient is prescribed long-term antiplatelet therapy. During the first two years, control coronary angiography is performed annually.
In severe cases of obliterating atherosclerosis of the coronary arteries, when there are no conditions for CABG and X-ray surgical interventions, the patient may be offered transmyocardial laser myocardial revascularization. In this case, the improvement of myocardial blood circulation occurs due to blood flow directly from the left ventricular cavity. The surgeon places a laser on the affected area of the myocardium, creating multiple channels with a diameter of less than 1 millimeter. The channels promote the growth of new blood vessels through which blood enters the ischemic myocardium, providing it with oxygen. This operation can be performed both independently and in combination with coronary artery bypass surgery.
After the elimination of aorto-coronary stenosis, the quality of life increases noticeably, working ability is restored, the risk of myocardial infarction and sudden cardiac death is significantly reduced, and life expectancy increases.
Currently, the diagnosis of coronary artery disease is not a sentence, but a reason for action on the choice of the optimal treatment tactics, which will save a life for many years.
IHD is a very common disease, one of the main causes of death, as well as temporary and permanent disability of the population in the developed countries of the world. In this regard, the problem of coronary artery disease is one of the leading places among the most important medical problems of the XXI century.
In the 80s. a tendency to a decrease in mortality from coronary heart disease has manifested itself, but nevertheless in the developed countries of Europe it was about half of the total mortality rate of the population, while maintaining a significant uneven distribution among the contingents of people of different sex and age. In the United States in the 80s. the mortality of males aged 35–44 years was about 60 per 100,000 population, with the ratio of deceased men and women at that age being about 5: 1. By the age of 65-74 years, the total mortality from coronary heart disease of both sexes reached more than 1600 per 100,000 population, and the ratio between dead men and women of this age group decreased to 2: 1.
The fate of IHD patients, who constitute a substantial part of the cohort observed by physicians, largely depends on the adequacy of the outpatient treatment carried out, on the quality and timeliness of diagnosis of those clinical forms of the disease that require emergency treatment or urgent hospitalization of the patient.
According to statistics in Europe, coronary artery disease and cerebral stroke determine 90% of all diseases of the cardiovascular system, which characterizes coronary artery disease as one of the most common diseases.
Classification Description of the disease
Everyone knows that the purpose of the heart muscle (myocardium) is to supply the body with oxygenated blood. However, the heart itself needs blood circulation. Arteries that deliver oxygen to the heart are called coronary. In total there are two such arteries, they depart from the aorta. Inside the heart, they branch out into many small 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 is constantly working and with a huge load. And if the manifestation of a lack of oxygen in other organs, a person may not particularly feel, then a lack of oxygen in the heart muscle immediately leads to negative consequences.
Insufficiency of blood circulation in the heart can occur only for one reason - if the coronary arteries miss a little blood. This condition is called "coronary heart disease" (CHD).
In the overwhelming majority of cases, the narrowing of the vessels of the heart is 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 coronary artery disease is atherosclerosis of the coronary vessels.
Atherosclerosis was previously considered a disease of the elderly. But now this is far from the case. Now atherosclerosis of heart vessels can also manifest itself in middle-aged people, mainly in men. In 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, interfere with 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 over the course of many years, without particularly manifesting itself, and without causing particular anxiety to a person, except in some cases. However, when the lumen of the most important arteries of the heart is 70% blocked, the symptoms become apparent. And if this figure reaches 90%, then this situation begins to threaten life.
Varieties of coronary heart disease
In clinical practice, there are several types of coronary heart disease. In most cases, coronary artery 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. With it, the only manifestation is rapid fatigability and shortness of breath even after minor physical exercises (walking / climbing stairs up several floors).
If the attacks of pain occur during physical exertion, then this indicates the development of angina pectoris. However, for some people with IHD, chest pains appear spontaneously, without any connection with physical exertion.
Also, the nature of the changes in the symptoms of angina may indicate whether coronary artery disease develops or not. If CHD does not progress, then this condition is called stable angina. A person with stable angina, while observing certain rules of behavior and with appropriate supportive therapy, can live for several decades.
It is quite another thing when attacks of angina pectoris become more and more difficult with time, and the pain is caused by less and less physical exertion. Such angina is called unstable. This condition is a reason to sound the alarm, because unstable angina pectoris inevitably ends with myocardial infarction, or even death.
Vasospastic angina pectoris or Prinzmetall angina pectoris are also distinguished into a certain group. This angina is caused by spasm of the coronary arteries of the heart. Often, spastic angina can also occur in patients with atherosclerosis of the coronary vessels. However, this kind of angina may not be combined with such a symptom.
Depending on the severity of angina, functional classes are divided into.
|Class||Physical activity limitations||Under what loads do heart attacks occur?|
|I||not||at high intensity|
|II||small||with medium (walking a distance of more than 500 m, climb to the third floor)|
|III||pronounced||at low (walking at a distance of 100-200 m, rise to the second floor)|
|IV||very high||at very low (with any walking, daily activities) or at rest|
Symptoms of coronary heart disease
Many people do not pay for signs of coronary heart disease, although they are fairly obvious. For example, it is fatigue, shortness of breath, after physical activity, pain and tingling in the region of the heart. Some patients believe that “this is the way it should be, because I am no longer young / not young.” However, this is an erroneous point of view. Angina and dyspnea on exertion are not the norm. This is evidence of severe heart disease and a reason for the early adoption of measures and access to a doctor.
In addition, coronary artery disease can manifest itself and other unpleasant symptoms, such as arrhythmias, bouts of dizziness, nausea, fatigue. There may be heartburn and colic in the stomach.
Ischemic Heart Disease Pain
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.
Ischemic heart disease pain is usually concentrated in the area of the heart. As mentioned above, pain in most cases occurs during exercise, severe stress. If the pain in the heart begins at rest, then during physical exertion, they tend to increase.
The pain is usually observed in the chest area. She can irradiate 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.
In men, abdominal pain is often observed, which is why angina can be mistaken for some kind of gastrointestinal disease. Also, pain in angina often occur in the morning.
What is dangerous ischemic heart disease
Many people suffering from coronary heart disease get used to their illness 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 serious consequences.
The most insidious complication of coronary heart disease is a condition that doctors call sudden coronary death. In other words, this is a cardiac arrest caused by myocardial electrical instability, which, in turn, develops against the background of coronary artery disease. Very often, sudden coronary death occurs in patients with latent IHD. In such patients, the symptoms are often either 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 is so deteriorated that its necrosis occurs. The muscle tissue of the affected area of the heart dies off, and scar tissue appears instead. This happens, of course, only if the heart attack does not lead to death.
A heart attack and IHD itself can lead to another complication, namely, to chronic heart failure. This is the name of the condition in which the heart does not properly perform its functions of pumping blood. And this, in turn, leads to diseases of other organs and violations of their work.
How is IBS
Above, we have indicated which symptoms are associated with coronary heart disease. Here we will address the question of how to determine whether a person has atherosclerotic changes in the vessels in the early stages, even at that moment when obvious evidence of CHD is not always observed. In addition, it is not always a sign such as pain in the heart, indicates coronary heart disease. Often it is caused by other causes, such as diseases associated with the nervous system, spine, various infections.
Examination of a patient complaining of negative effects typical of coronary heart disease begins with listening to his heart tones. Sometimes the disease is accompanied by noise typical of IBS. However, often this method fails to reveal any pathology.
The most common method of instrumental study of the activity of the heart is the cardiogram. It can be used to track the spread of nerve signals in the heart muscle and how its departments are reduced. Very often, the presence of CHD is reflected in the form of changes on the ECG. However, this is not always the case, especially in the early stages of the disease. Therefore, a cardiogram with a load 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 activity, 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 taken for a long period of time, usually during the day. This allows you to notice individual abnormalities in the work of the heart, which may not be present on an ordinary cardiogram. Holter monitoring is carried out using a special portable cardiograph, which the person constantly carries in a special bag. In this case, the doctor attaches electrodes to the human chest, exactly the same as with a conventional cardiogram.
Also very informative is the method of echocardiogram - ultrasound of the heart muscle. Using an echocardiogram, a doctor can assess the performance of the heart muscle, the size of its parts, and the parameters of blood flow.
In addition, informative in the diagnosis of coronary artery disease are:
- general blood analysis,
- blood chemistry,
- blood test for glucose,
- blood pressure measurement
- selective coronography with a contrast agent,
- CT scan,
Many of these methods make it possible to identify not only the coronary artery disease itself, but also the accompanying diseases that aggravate the course of the disease, such as diabetes, hypertension, and blood and kidney diseases.
Treatment of CHD
Treatment of coronary artery 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 desire of the patient himself to cope with the illness. At the same time, it is necessary to be prepared for the fact that complete cure of IHD is usually impossible, since the processes in the vessels of the heart are in most cases irreversible. However, modern methods can extend the life of a person suffering from the disease for many decades and prevent his premature death. And not just to prolong life, but to make it full-fledged, not much different from the life of healthy people.
Treatment in the first stage of the disease usually includes only conservative methods. They are divided into drug and non-drug. Currently, in medicine, the most up-to-date is the scheme for treating a disease called ABC. It includes three main components:
- antiplatelet and anticoagulants,
- beta blockers,
What are these classes of drugs for? Antiplatelet agents interfere with platelet aggregation, thereby reducing the likelihood of the formation of intravascular blood clots. The most effective antiplatelet agent with the greatest evidence base is acetylsalicylic acid. This is the same Aspirin that our grandparents used to treat colds and flu. However, conventional aspirin tablets as a permanent medication taken are not suitable for coronary heart disease. The fact is that taking acetylsalicylic acid carries with it the threat of gastric irritation, the occurrence of peptic ulcer and intragastric bleeding. Therefore, acetylsalicylic acid tablets for cores are usually coated with a special enteric coating. Or acetylsalicylic acid is mixed with other components, preventing its contact with the gastric mucosa, as, for example, in Cardiomagnyl.
Anticoagulants also prevent the formation of blood clots, but have a completely different mechanism of action than antiplatelet agents. The most common drug of this type is heparin.
Beta adrenoblockers interfere with 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 need for oxygen. Examples of modern beta-blockers are metoprolol, propranolol. However, this type of medication is not always prescribed for IHD, as it has a number of contraindications, for example, some types of arrhythmias, bradycardia, hypotension.
The third class of first-line drugs for the treatment of coronary artery disease are drugs to reduce harmful cholesterol in the blood (statins). The most effective among the statins is atorvastatin. During the six months of therapy with this drug, atherosclerotic plaques in patients are reduced by an average of 12%. However, other types of statins can be prescribed by a doctor - lovastatin, simvastatin, rosuvastatin.
Drugs of the class of fibrates are also intended to reduce bad glycerol. However, the mechanism of their action is not direct, but indirect - thanks to them, the ability of high-density lipoproteins to process “bad” cholesterol increases. Both types of drugs - fibrates and statins can be administered together.
Also with IHD can be used other drugs:
- antihypertensive drugs (if ischemic heart disease is accompanied by hypertension),
- diuretic drugs (with poor kidney function),
- hypoglycemic drugs (with concomitant diabetes),
- metabolic agents (improving metabolic processes in the heart, for example, mildronate),
- sedatives and tranquilizers (to reduce stress and relieve anxiety).
However, the most commonly used type of drugs taken directly during the onset of angina pectoris are nitrates. They have a pronounced vasodilating effect, help relieve pain and prevent such a terrible consequence of coronary artery disease, like myocardial infarction. The most famous drug of this type, used since the century before last, is nitroglycerin. However, it is worth remembering that nitroglycerin and other nitrates are symptomatic means for a single dose. Their regular use does not improve the prognosis for coronary heart disease.
The second group of non-drug methods of combating CHD is physical exercise. Of course, during the period of exacerbation of the disease, with unstable angina, any serious loads are prohibited, since they can be fatal. However, during the rehabilitation period, the patients are shown gymnastics and various physical exercises, as prescribed by a doctor. Such a metered load trains the heart, makes it more resistant to lack of oxygen, and also helps control body weight.
In the event that the use of medicines and other types of conservative therapy do not lead to improvement, then more radical methods are used, including surgical ones. The most modern method of treating ischemic heart disease is balloon angioplasty, often combined with subsequent stenting. The essence of this method lies in the fact that a miniature balloon is introduced into the lumen of the constricted vessel, which is then inflated with air and then blown off. As a result, the lumen of the vessel is greatly expanded. However, after some time, the lumen may narrow again. To prevent this from happening from within, the walls of the artery are strengthened with a special frame. This operation is called stenting.
However, in some cases, and angioplasty is powerless to help the patient. Then the only way out is coronary artery bypass surgery. The essence of the operation is to circumvent the affected area of the vessel and connect the two segments of the artery, in which atherosclerosis is not observed. For this purpose, a small piece of a vein from another part of the body is taken from the patient and transplanted instead of the damaged part of the artery. Through this operation, the blood gets the opportunity to get to the necessary parts of the heart muscle.
It is well known that treatment is always more difficult than avoiding the disease. This is especially true of such a severe and sometimes incurable disease, as ischemic heart disease. Millions of people around the world and in our country suffer from this heart disease. But in most cases it is not the unfavorable set of circumstances, hereditary or external factors that are to blame for the occurrence of the disease, but the person himself, his wrong lifestyle and behavior.
Recall once again the factors that often lead to the early incidence of CHD:
- sedentary lifestyle,
- a diet that contains large amounts of harmful cholesterol and simple carbohydrates,
- constant stress and fatigue,
- uncontrolled hypertension and diabetes,
To change something in this list, making it so that this problem would disappear from our life and we would not have to be treated for CHD, the strength of most of us.
It is accepted to allocate the chronic and acute form of an ischemic heart disease. The first category includes heart failure, arrhythmia, cardiosclerosis. Acute ischemia includes sudden death, unstable angina, and heart attack. There are also several classes of the disease, which are characterized by certain features:
- Walking or climbing stairs does not cause seizures. Symptoms of pathology occur during prolonged or intense loads.
- There is a slight limitation of motor activity. The attack sometimes develops after waking up, eating, stressful situation.
- Significant limitation of activity. Attack overtakes after 200 meters of familiar walking.
- Completely lost the ability to perform any physical work. Angina pains appear even in a calm state.
Sudden coronary death
By this term is meant a natural death. In men, cardiac arrest is more common than in women at a 10: 1 ratio. This form of the disease in most cases is associated with ventricular fibrillation, when there is a chaotic contraction of different heart fibers at a heart rate of 300-600 beats / minute. This condition is not adequate to normal blood circulation, therefore it is not compatible with life. Less commonly, this form of coronary artery disease may be associated with asystole or bradycardia.
CHD - angina pectoris
By this condition is understood ischemic syndrome, which is manifested by chest pain, radiating to epigastrium, jaw, upper limbs, neck. The immediate cause of the pathology is insufficient blood supply to the heart muscle. Stable angina pectoris is easily relieved by medication, as it has stereotypical seizures. Unstable violation sometimes leads to myocardial infarction or death. The spontaneous form (chronic heart failure) manifests itself even in a calm state and has a vasospastic origin.
CHD - cardiosclerosis
When the connective scar tissue grows in the myocardium, and the valves are deformed, this pathology is called cardiosclerosis. This condition is a manifestation of chronic coronary artery disease. The atherosclerotic form of the disease has a long developmental process, and its progression disrupts the heart rhythm, which provokes necrotic changes and scarring of myocardial tissues. Sclerotic changes lead to the development of acquired heart disease or bradycardia.
CHD - myocardial infarction
Necrosis of the muscle layer caused by insufficient blood supply is called myocardial infarction. This form of CHD - what is it? The disease in clinical manifestation allocates three degrees: pain (1-2 days), febrile (7-15 days), scarring (2-6 months). The infarction is preceded, as a rule, by the exacerbation of IHD, which is manifested in the intensification of angina attacks, the sensation of an abnormal heart rhythm, and the initial signs of heart failure. This condition is called preinfarction.
Arrhythmic form of CHD
In medicine, arrhythmia is called a disruption of the heart when the regularity and frequency of contractions change.Arrhythmic form of coronary artery disease is the most common, since it is often the only symptom of the disease. Not only chronic coronary heart disease, but also bad habits, prolonged stress, drug abuse, and other diseases can provoke arrhythmia. This form of IHD is characterized by slow or rapid heartbeat due to the disruption of the functionality of electrical impulses.
Painless form of CHD
This is a temporary impairment of the myocardial blood supply, which is not accompanied by a painful attack, but is recorded on a cardiogram. The painless form of IHD may manifest itself or be combined with other forms of myocardial ischemia. According to the classification, it is divided into several types:
- The first. It is diagnosed in patients with coronary angiography, but only if other forms of coronary artery disease have not been previously detected.
- Second. Appears in people who have had a heart attack, but without attacks of angina.
- Third. It is diagnosed in patients with a diagnosis of progressive angina.
CHD - symptoms
Ischemia of the heart has symptoms of physical and mental manifestations. The first is arrhythmia, weakness, shortness of breath, increased sweating. The patient has spontaneous chest pains that do not stop even after taking nitroglycerin, he becomes very pale. Mental symptoms of IHD:
- severe lack of oxygen
- apathy, sad mood,
- panic fear of death,
- causeless anxiety.
In case of myocardial ischemia, for successful treatment of pathology, doctors distinguish clinical symptoms by the forms of IHD:
- Coronary death Symptoms develop rapidly: the pupils do not react to light, there is no consciousness, pulse, or breathing.
- Angina pectoris Pressing, cutting, compressing and burning pain is localized in the epigastrium or behind the sternum. An attack of angina pectoris lasts from 2 to 5 minutes, and is quickly stopped by drugs. Vasospastic angina is characterized by a feeling of discomfort behind the sternum at rest. When first developed angina, an increase in blood pressure is observed, spontaneous attacks up to 15 minutes during physical exertion. Early postinfarction angina occurs after myocardial infarction.
- Cardiosclerosis. There is pulmonary edema, diffuse or focal myocardial damage, aneurysm rupture, persistent cardiac rhythm. The patient appears swelling of the feet, lack of air, dizziness, with time - pain in the hypochondrium, an increase in the abdomen. Postinfarction cardiosclerosis is characterized by attacks of nocturnal asthma, tachycardia, progressive dyspnea.
- Heart attack. Severe pain behind the sternum, extending to the jaw, left shoulder blade and arm. Continues up to half an hour, when taking nitroglycerin does not pass. The patient appears cold sweat, a sharp decrease in blood pressure, weakness, vomiting, fear of death.
- Coronary X syndrome. Compressive or compressive pain in the atrial area or behind the sternum, which lasts up to 10 minutes.
Diagnosis of CHD
Determining the form of myocardial ischemia is an important and difficult process. The successful prescription of pharmacotherapy depends on the correct diagnosis. The main diagnosis of coronary artery disease is a survey of the patient and physical research. After installing the cause and extent of the disorder, the specialist prescribes the following diagnostic methods:
- urine and blood tests (general, biochemical),
- Holter monitoring,
- electrocardiography (ECG),
- echocardiography (echocardiography)
- functional tests
- Ultrasound of the heart,
- intra esophageal electrocardiography.
CHD - treatment
Also on the basis of laboratory parameters, the doctor prescribes, in addition to the diet and the installation of a benign regimen, the treatment of IHD with drugs from the following pharmacological groups:
- β-blockers. Atenol, Prinorm.
- Antiarrhythmic drugs. Amiodarone, Lorcaine.
- Antiplatelet and anticoagulants. Verapamil, Warfarin.
- Antioxidants. Mexicor, Ethyl methyl hydroxypyridine.
- Angiotensin-converting enzyme inhibitors. Captopril, Lisinopril, Enalapril.
- Nitrates Nitroglycerin, isosorbide mononitrate.
- Diuretics. Hypothiazide, Indapamide.
- Natural lipid-lowering drugs. Atorvastatin, Mildronat, Rosuvastatin, Trimetazidine.
- Statins. Lovastatin, Simvastatin.
- Fibrates. Fenofibrat, Miscleron.
Coronary heart disease is the most serious problem of modern cardiology and medicine in general. In Russia, about 700 thousand deaths caused by various forms of IHD are recorded annually in the world, and the death rate from IHD is about 70%. Coronary artery disease is more likely to affect men of active age (55 to 64 years old), leading to disability or sudden death.
At the heart of the development of coronary artery disease is an imbalance between the need of the heart muscle in the blood supply and the actual coronary blood flow. This imbalance may develop due to the sharply increased need of the myocardium in the blood supply, but its insufficient implementation, or with the usual need, but a sharp decrease in the coronary circulation. The lack of blood supply to the myocardium is especially pronounced in cases when the coronary blood flow is reduced and the need of the heart muscle for blood flow increases dramatically. Insufficient blood supply to the tissues of the heart, their oxygen starvation is manifested by various forms of coronary heart disease. The group of CHD includes acutely developing and chronically occurring states of myocardial ischemia, followed by its subsequent changes: dystrophy, necrosis, sclerosis. These conditions in cardiology are considered, among other things, as independent nosological units.
Causes and risk factors
The overwhelming majority (97-98%) of clinical cases of coronary artery disease are caused by atherosclerosis of the coronary arteries of varying severity: from a slight narrowing of the lumen of an atherosclerotic plaque to complete vascular occlusion. At 75% coronary stenosis, the heart muscle cells respond to oxygen deficiency, and patients develop angina.
Other causes of coronary artery disease are thromboembolism or spasm of the coronary arteries, usually developing against the background of an existing atherosclerotic lesion. Cardiospasm aggravates obstruction of the coronary vessels and causes manifestations of coronary heart disease.
Factors contributing to the occurrence of CHD include:
Contributes to the development of atherosclerosis and increases the risk of coronary heart disease by 2-5 times. The most dangerous in terms of the risk of coronary artery disease are hyperlipidemia types IIa, IIb, III, IV, as well as a decrease in the content of alpha-lipoproteins.
Hypertension increases the likelihood of developing CHD 2-6 times. In patients with systolic blood pressure = 180 mm Hg. Art. and higher ischemic heart disease is found up to 8 times more often than in hypotensive people and people with normal blood pressure levels.
According to various data, smoking cigarettes increases the incidence of coronary artery disease by 1.5-6 times. Mortality from coronary heart disease among men 35-64 years old, smoking 20-30 cigarettes daily, is 2 times higher than among non-smokers of the same age category.
Physically inactive people are at risk for CHD 3 times more than those who lead an active lifestyle. When combined hypodynamia with overweight, this risk increases significantly.
- impaired carbohydrate tolerance
In case of diabetes mellitus, including latent diabetes, the risk of the incidence of coronary heart disease increases by 2-4 times.
The factors that pose a threat to the development of CHD should also include the burdened heredity, male gender and elderly patients. With a combination of several predisposing factors, the degree of risk in the development of coronary heart disease increases significantly.
The causes and speed of ischemia, its duration and severity, the initial state of the individual's cardiovascular system determine the occurrence of one or another form of ischemic heart disease.
Symptoms of CHD
The clinical manifestations of coronary artery disease are determined by the specific form of the disease (see myocardial infarction, angina). In general, coronary heart disease has a wavelike course: periods of stably normal state of health alternate with episodes of acute ischemia. About 1/3 of patients, especially with silent myocardial ischemia, do not feel the presence of IHD at all. The progression of coronary heart disease can develop slowly over decades, and the forms of the disease and, consequently, the symptoms may change.
Common manifestations of coronary artery disease include chest pains associated with physical exertion or stress, pain in the back, arm, lower jaw, shortness of breath, increased heartbeat or a sense of interruption, weakness, nausea, dizziness, clouding of consciousness and fainting, excessive sweating. Often, coronary artery disease is detected at the stage of development of chronic heart failure with the appearance of edema in the lower extremities, severe shortness of breath, forcing the patient to take a forced sitting position.
These symptoms of coronary heart disease usually do not occur at the same time, with a certain form of the disease there is a predominance of certain manifestations of ischemia.
The harbingers of primary cardiac arrest in patients with ischemic heart disease may be episodic arising sensations of discomfort behind the sternum, fear of death, and psycho-emotional lability. With sudden coronary death, the patient loses consciousness, there is a cessation of breathing, there is no pulse on the main arteries (femoral, carotid), heart sounds are not heard, the pupils dilate, the skin becomes a pale grayish tint. Cases of primary cardiac arrest make up to 60% of deaths from coronary heart disease, mainly in the prehospital phase.
Hemodynamic disturbances in the heart muscle and its ischemic damage cause numerous morpho-functional changes that determine the shape and prognosis of coronary artery disease. The result of myocardial ischemia are the following mechanisms of decompensation:
- lack of energy metabolism of myocardial cells - cardiomyocytes,
- “Stunned” and “sleeping” (or hibernating) myocardium - a form of impaired left ventricular contractility in patients with coronary artery disease, having a transient nature,
- development of diffuse atherosclerotic and focal post-infarction cardiosclerosis - reducing the number of functioning cardiomyocytes and the development of connective tissue in their place,
- violation of systolic and diastolic functions of the myocardium,
- disorder of excitability, conductivity, automatism and myocardial contractility.
The listed morpho-functional changes in the myocardium in ischemic heart disease lead to the development of a persistent decrease in the coronary circulation, i.e. heart failure.
Diagnosis of coronary artery disease is carried out by cardiologists in a cardiological hospital or clinic with the use of specific instrumental techniques. When interviewing a patient, complaints and symptoms typical for coronary heart disease are clarified. On examination, the presence of edema, cyanosis of the skin, heart murmurs, and rhythm disturbances are determined.
Laboratory and diagnostic tests involve the study of specific enzymes that increase with unstable angina and infarction (creatine phosphokinase (during the first 4-8 hours), troponin-I (7-10 days), troponin-T (10-14 days), aminotransferase , lactate dehydrogenase, myoglobin (on the first day)). These intracellular protein enzymes in the destruction of cardiomyocytes are released into the blood (resorption-necrotic syndrome). A study is also conducted on the level of total cholesterol, low (atherogenic) and high (anti-atherogenic) density lipoproteins, triglycerides, blood sugar, ALT and AST (nonspecific cytolysis markers).
The most important method for the diagnosis of cardiac diseases, including coronary heart disease, is an ECG - registration of the electrical activity of the heart, which allows to detect violations of the normal mode of myocardial function. Echocardiography - a method of ultrasound of the heart allows you to visualize the size of the heart, the condition of the cavities and valves, assess the contractility of the myocardium, acoustic noise. In some cases, coronary artery disease with stress echocardiography - ultrasound diagnosis using dosage exercise, recording myocardial ischemia.
In the diagnosis of coronary heart disease, functional tests with a load are widely used. They are used to identify the early stages of coronary artery disease, when violations are still impossible to determine at rest. As a stress test, walking, climbing stairs, loads on simulators (exercise bike, treadmill) are used, accompanied by ECG-fixation of cardiac performance. The limited use of functional tests in some cases caused by the inability of patients to perform the required amount of load.
Holter daily monitoring of ECG involves the registration of an ECG performed during the day and detecting intermittent abnormalities in the heart. For the study, a portable device (Holter monitor) is used, fixed on the shoulder or belt of the patient and taking readings, as well as a self-observation diary in which the patient watches his or her actions and changes in the state of health by the hours. The data obtained during the monitoring process are processed on the computer. ECG monitoring allows not only to identify manifestations of coronary heart disease, but also the causes and conditions for their occurrence, which is especially important in the diagnosis of angina.
Extraesophageal electrocardiography (CPECG) allows a detailed assessment of electrical excitability and conductivity of the myocardium. The essence of the method consists in inserting a sensor into the esophagus and recording heart performance indicators, bypassing the disturbances created by the skin, subcutaneous fat, and the rib cage.
Conducting coronary angiography in the diagnosis of coronary heart disease allows to contrast the myocardial vessels and determine violations of their patency, the degree of stenosis or occlusion. Coronary angiography is used to address the issue of cardiac vascular surgery. With the introduction of a contrast agent possible allergic phenomena, including anaphylaxis.
Prognosis and prevention
The definition of the prognosis for CHD depends on the interrelation of various factors. So adversely affects the prognosis of a combination of coronary heart disease and arterial hypertension, severe disorders of lipid metabolism and diabetes. Treatment can only slow down the steady progression of coronary artery disease, but not stop its development.
The most effective prevention of CHD is to reduce the adverse effects of threats: the elimination of alcohol and tobacco, psycho-emotional overload, maintaining optimal body weight, physical activity, blood pressure control, healthy eating.