/ 07.11.2017

Cardiac ischemia. Sudden death due to coronary heart disease. Acute coronary heart disease death

Acute coronary heart disease (CHD) is a common disease that occurs in men and women in old age. The danger of this ailment is that it can be asymptomatic, only in some cases pain in the heart appears. Acute myocardial ischemia causes extensive infarction, which is often fatal. Therefore, it is recommended to know the symptoms of pathology and immediately consult a doctor in order to take measures for timely treatment.

Causes

Ischemic myocardial disease is manifested due to poor blood supply. This condition is explained by the fact that less oxygen is supplied to the heart muscle than needed.

Violation of blood supply occurs:

1. In case of damage to the inner part of the vessels: atherosclerosis, spasm or blood clots.
2. External pathology: tachycardia, arterial hypertension.

The main risk factors are:

• retirement age;
• male population;
• smoking;
• drinking alcoholic beverages;
• hereditary predisposition;
• diabetes;
• hypertension;
• excess weight.

In most cases, acute coronary heart disease occurs in people of pre-retirement age and older. Indeed, over time, the vessels lose their elasticity, plaques form in them and metabolic processes are disrupted. Often, pathology occurs in men, since a change in hormonal levels in women protects them from cardiac ischemia. However, when permanent menopause occurs, the risk of cardiovascular disease increases.

A poor lifestyle also affects the development of coronary heart disease. The consumption of fatty foods in large quantities, soda, alcohol negatively affects the state of blood vessels.

A large fat metabolism promotes the formation of plaque on the walls of the arteries, which disrupt blood flow and lead to oxygen starvation of the heart tissues. Therefore, the risk group for CHD includes people who are overweight and diabetes mellitus.

Manifestation of the disease

The main symptom of acute and chronic ischemic heart disease is pain in the chest and shortness of breath. The disease may not appear immediately if the blockage of the arteries occurs gradually. There are cases when this process begins suddenly, that is, an acute myocardial infarction develops.

Common signs of ailment:

• spasm in the left hypochondrium;
• labored breathing;
• excessive sweating;
• vomiting and nausea;

• dizziness;
• cardiopalmus;
• anxiety;
• sudden cough.

The clinical course of ischemia primarily depends on the degree of damage to the artery. Often, angina pectoris occurs during exercise. For example, a person climbed the stairs and ran a short distance, there was a pain syndrome in the chest.

Common signs of cardiac ischemia are:

• chest pain on the left, may radiate to the arms and back;
• shortness of breath when walking fast.

Therefore, in case of heart attacks, you should immediately contact a medical institution. If ischemia is left untreated, signs of heart failure may occur. The syndrome is characterized by cyanotic skin, edema of the legs, gradually fluid is observed in the chest cavity, peritoneum. Weakness and shortness of breath appear.

Ischemic heart disease angina pectoris, acute myocardial infarction Symptoms, diagnostics +)

Ischemia is a manifestation of a mismatch between the need for and the supply of oxygen to the heart. This may most often depend on a violation of blood flow to the heart muscle in atherosclerosis of the coronary arteries, which is noted by cardiologists in almost 90% of all cases of angina pectoris and only in 10% of cases of other pathological conditions (metabolic diseases, endocrine disorders, rheumatic valve defects, inflammatory and allergic vascular diseases, etc.).
Normally, myocardial oxygen demand and its supply with blood flowing to the coronary arteries of the heart is a self-regulating process. And with ischemic heart disease, this self-regulation is impaired and entails the well-known clinical manifestations of angina pectoris, or the so-called angina pectoris.

For those suffering from myocardial infarction, the well-known scheme of the stages of rehabilitation hospital - clinic - sanatorium is transformed into a hospital - sanatorium - polyclinic scheme.
Spa treatment is an important link in the system of therapeutic and prophylactic measures for ischemic heart disease. The natural factors of resorts (climate, mineral waters, etc.) have active properties to regulate impaired physiological functions in cardiac patients, to inhibit the development and progression of the pathological process.

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 ischemic heart disease occupies one of the leading places among the most important medical problems of the XX century.

In the 80s. there was a tendency towards a decrease in mortality from ischemic heart disease, but nevertheless in the developed countries of Europe it amounted to about half of the total mortality of the population, while maintaining a significant uneven distribution among the contingents of persons of different sex and age. In the USA in the 80s. the mortality rate for men aged 35-44 was about 60 per 100,000 population, and the ratio of men and women who died at this age was about 5: 1. By the age of 65-74 years, the total mortality from CHD in persons of both sexes reached more than 1600 per 100,000 of the population, and the ratio between the deceased men and women in this age group decreased to 2: 1.

The fate of patients with coronary artery disease, who make up a significant part of the contingent observed by doctors, largely depends on the adequacy of the outpatient treatment, on the quality and timeliness of diagnostics of those clinical forms of the disease that require the provision of emergency care or urgent hospitalization to the patient.

According to statistics in Europe, IHD and cerebral stroke determine 90% of all diseases of the cardiovascular system, which characterizes ischemic heart disease as one of the most common diseases.

Classification

The classification of ischemic heart disease according to clinical forms is used, each of which has an independent meaning due to the peculiarities of clinical manifestations, prognosis and elements of therapeutic tactics. It was recommended in 1979 by a group of WHO experts.

1. Sudden coronary death (primary cardiac arrest).
2. Angina pectoris
   • Stable exertional angina (with indication of the functional class).
   • Coronary syndrome X
   • Vasospastic angina
   • Unstable angina
     • progressive angina
     • first-onset angina
     • early postinfarction angina
3. Myocardial infarction
4. Cardiosclerosis
5. Painless form of ischemic heart disease

It is unacceptable to formulate the diagnosis of ischemic heart disease without decoding the form, since in such a general form it does not give real information about the nature of the disease. In a correctly formulated diagnosis, the specific clinical form of the disease follows the diagnosis of coronary artery disease through the colon, for example: "IHD: first-onset angina pectoris"; in this case, the clinical form is indicated in the designation provided for by the classification of this form.

Also today there is a more modern classification. This is the WHO classification of IHD with additions VKNC, 1984.

1. Sudden coronary death (primary cardiac arrest)
   • Sudden coronary death with successful resuscitation
   • Sudden coronary death (death)
2. Angina pectoris
   • Exertional angina
     • New-onset angina pectoris
     • Stable exertional angina with functional class
   • Unstable angina (currently Braunwald graded)
   • Vasospastic angina
3. Myocardial infarction
4. Postinfarction cardiosclerosis
5. Heart rhythm disorders
6. Heart failure

Currently, the Braunwald classification, developed at the end of the 80s, is used to determine the severity of unstable angina.

Risk factors for the development of ischemic heart disease

Risk factors for coronary heart disease are circumstances that predispose to the development of coronary heart disease. These factors are largely similar to the risk factors for atherosclerosis, since the main link in the pathogenesis of coronary heart disease is atherosclerosis of the coronary arteries.

Various models have been proposed in epidemiological studies to classify the many risk factors associated with cardiovascular disease. Risk indicators can be classified as follows.

Biological determinants or factors:

• elderly age;
• male gender;
• genetic factors contributing to dyslipidemia, hypertension, glucose tolerance, diabetes mellitus and obesity.

Anatomical, physiological and metabolic (biochemical) features:

• dyslipidemia;
• arterial hypertension;
• obesity and the nature of the distribution of body fat;
• diabetes.

Behavioral (behavioral) factors that can lead to an exacerbation of coronary artery disease:

• food habits;
• smoking;
• insufficient, or physical activity exceeding the adaptive capabilities of the body;
• alcohol consumption;
• Behavior that contributes to coronary artery disease.

The likelihood of developing coronary heart disease and other cardiovascular diseases increases with an increase in the number and "power" of these risk factors.

For a doctor who determines the nature and scope of preventive and therapeutic interventions, both the recognition of risk factors at the individual level and a comparative assessment of their significance are important. First of all, it is necessary to identify atherogenic dyslipoproteinemia at least at the level of detection of hypercholesterolemia (deviation of the concentration of cholesterol in the blood towards an increase in comparison with the norm). It has been proven that with a serum cholesterol content of 5.0-5.2 mmol / l, the risk of death from coronary heart disease is relatively low. The number of deaths from coronary artery disease over the next year increases from 5 cases per 1000 men with a blood cholesterol level of 5.2 mmol / L to 9 cases with a blood cholesterol level of 6.2-6.5 mmol / L and up to 17 cases per 1000 population with a blood cholesterol level of 7.8 mmol / l. This pattern is typical for all people aged 20 and over. The opinion about the increase in the border of the permissible level of cholesterol in the blood in adults with increasing age as a normal phenomenon turned out to be untenable.

Hypercholesterolemia refers to important elements of the pathogenesis of atherosclerosis of any arteries; the question of the reasons for the predominant formation of atherosclerotic plaques in the arteries of this or that organ (brain, heart, extremities) or in the aorta has not been sufficiently studied. One of the possible prerequisites for the formation of stenosing atherosclerotic plaques in the coronary arteries may be the presence of muscular-elastic hyperplasia of their intima (its thickness may exceed the thickness of the media by 2-5 times). Hyperplasia of the intima of the coronary arteries, detected already in childhood, can be attributed to the factors of hereditary predisposition to coronary heart disease.

Pathogenesis

According to modern concepts, coronary heart disease is a pathology based on myocardial damage caused by insufficient blood supply (coronary insufficiency). An imbalance between the real blood supply to the myocardium and its needs for blood supply can occur due to the following circumstances:

1. Causes inside the vessel:
   • atherosclerotic narrowing of the lumen of the coronary arteries;
   • thrombosis and thromboembolism of the coronary arteries;
   • spasm of the coronary arteries.
2. Reasons outside the vessel:
   • tachycardia;
   • myocardial hypertrophy;
   • arterial hypertension.

The concept of ischemic heart disease is a group. It combines both acute and chronic conditions, including those considered as independent nosological forms, which are based on ischemia and the changes in the myocardium caused by it (necrosis, dystrophy, sclerosis); but only in cases where ischemia is due to narrowing of the lumen of the coronary arteries associated with atherosclerosis, or the reason for the inconsistency of coronary blood flow with the metabolic needs of the myocardium is not known.

The formation of an atherosclerotic plaque occurs in several stages. At first, the vessel lumen does not change significantly. As lipids accumulate in the plaque, ruptures of its fibrous cover appear, which is accompanied by the deposition of platelet aggregates, which contribute to the local deposition of fibrin. The area of ​​the parietal thrombus is covered with the newly formed endothelium and protrudes into the lumen of the vessel, narrowing it. Along with lipid-fibrous plaques, fibrous stenosing plaques, which undergo calcification, are formed almost exclusively.

As each plaque develops and increases, the number of plaques increases, so does the degree of stenosis of the lumen of the coronary arteries, which largely (although not necessarily) determines the severity of clinical manifestations and the course of coronary artery disease. Narrowing of the lumen of the artery by up to 50% is often asymptomatic. Usually, clear clinical manifestations of the disease occur when the lumen is narrowed to 70% or more. The more proximally the stenosis is, the greater the mass of the myocardium undergoes ischemia in accordance with the zone of blood supply. The most severe manifestations of myocardial ischemia are observed with stenosis of the main trunk or the mouth of the left coronary artery.

In the origin of myocardial ischemia, a sharp increase in its oxygen demand, coronary angiospasm or thrombosis can often play a role. The prerequisites for thrombosis due to damage to the vascular endothelium may arise already in the early stages of atherosclerotic plaque development, especially since in the pathogenesis of coronary artery disease, and especially its exacerbation, the processes of hemostasis disturbance play a significant role, primarily the activation of platelets, the causes of which are not fully established. Platelet microthrombosis and microembolism can aggravate blood flow disturbances in a stenotic vessel.

Significant atherosclerotic arterial disease does not always prevent their spasm. The study of serial cross sections of the affected coronary arteries showed that in only 20% of cases, atherosclerotic plaque causes concentric narrowing of the artery, which prevents functional changes in its lumen. In 80% of cases, an eccentric location of the plaque is detected, in which the vessel's ability to expand and spasm remains.

Pathological anatomy

The nature of the changes found in IHD depends on the clinical form of the disease and the presence of complications - heart failure, thrombosis, thromboembolism, etc.

With myocardial infarction

Histological specimen (magnification 100x, staining with hematoxylin-eosin). Myocardial infarction seven days ago.

The most pronounced morphological changes in the heart in myocardial infarction and postinfarction cardiosclerosis. Common to all clinical forms of coronary artery disease is the picture of atherosclerotic lesions (or thrombosis) of the arteries of the heart, usually detected in the proximal parts of the large coronary arteries. Most often, the anterior interventricular branch of the left coronary artery is affected, less often the right coronary artery and the enveloping branch of the left coronary artery. In some cases, stenosis of the trunk of the left coronary artery is found. In the basin of the affected artery, changes in the myocardium are often determined, corresponding to its ischemia.

or fibrosis, mosaic changes are characteristic (the affected areas are adjacent to the unaffected areas of the myocardium); with complete blockage of the lumen of the coronary artery in the myocardium, as a rule, a postinfarction scar is found. In patients who have had myocardial infarction, aneurysm of the heart, perforation of the interventricular septum, avulsion of papillary muscles and chords, and intracardiac thrombi can be found.

With angina

There is no clear correspondence between the manifestations of angina pectoris and anatomical changes in the coronary arteries, however, it has been shown that stable angina pectoris is more characterized by the presence of atherosclerotic plaques in the vessels with a smooth endothelium-covered surface, while with progressive angina, plaques with ulceration, rupture, and formation of parietal blood clots.

Clinical forms

To substantiate the diagnosis of ischemic heart disease, it is necessary to establish evidence-based its clinical form (from among those presented in the classification) according to the generally accepted diagnostic criteria for this disease. In most cases, recognition of angina pectoris or myocardial infarction, the most frequent and most typical manifestations of coronary heart disease, is of key importance for the diagnosis; other clinical forms of the disease are less common in everyday medical practice and their diagnosis is more difficult.

Sudden coronary death

Sudden coronary death (primary cardiac arrest) is thought to be related to electrical instability in the myocardium. Sudden death is referred to as an independent form of IHD if there is no reason for a diagnosis of another form of IHD or another disease: for example, death that occurs in the early phase of myocardial infarction is not included in this class and should be considered as death from myocardial infarction. If resuscitation is not performed or was unsuccessful, then primary cardiac arrest is classified as sudden coronary death. The latter is defined as death that occurs in the presence of witnesses instantly or within 6 hours from the onset of a heart attack.

Angina pectoris

Angina as a form of manifestation of coronary artery disease unites exertional angina, subdivided into:

• first emerging
• stable
• progressive
• spontaneous angina pectoris (so-called rest angina), a variant of which is Prinzmetal's angina.

Exertional angina

Exertional angina characterized by transient attacks of chest pain caused by physical or emotional stress or other factors leading to an increase in the metabolic requirements of the myocardium (increased blood pressure, tachycardia). In typical cases of angina pectoris, the chest pain that appears during physical or emotional stress (heaviness, burning, discomfort) usually radiates to the left arm, scapula. Quite rarely, the localization and irradiation of pain are atypical. An attack of angina pectoris lasts from 1 to 10 minutes, sometimes up to 30 minutes, but no more. The pain, as a rule, quickly stops after the termination of the load or 2-4 minutes after sublingual intake (under the tongue) of nitroglycerin.

First emerging angina pectoris is diverse in manifestations and prognosis, therefore, it cannot be confidently attributed to the category of angina pectoris with a certain course without the results of monitoring the patient in dynamics. The diagnosis is established within a period of up to 3 months from the date of the patient's first painful attack. During this time, the course of angina pectoris is determined: its convergence to nothing, the transition to stable or progressive.

Diagnosis stable angina stresses are established in cases of a stable manifestation of the disease in the form of a regular occurrence of pain attacks (or ECG changes preceding an attack) for a load of a certain level for a period of at least 3 months. The severity of stable exertional angina characterizes the threshold level of physical activity tolerated by the patient, according to which the functional class of its severity is determined, which must be indicated in the formulated diagnosis.

Progressive angina stress is characterized by a relatively rapid increase in the frequency and severity of pain attacks with a decrease in exercise tolerance. Attacks occur at rest or with less stress than before, it is more difficult to stop with nitroglycerin (often an increase in its single dose is required), sometimes they are stopped only by the introduction of narcotic analgesics.

Spontaneous angina differs from exertional angina in that painful attacks occur without a visible connection with factors leading to an increase in the metabolic requirements of the myocardium. Attacks can develop at rest without obvious provocation, often at night or in the early hours, and sometimes are cyclical. In terms of localization, irradiation and duration, the effectiveness of nitroglycerin, attacks of spontaneous angina pectoris differ little from attacks of exertional angina.

Variant angina, or Prinzmetal angina, indicate cases of spontaneous angina pectoris, accompanied by transient elevations in the ECG of the ST segment.

Myocardial infarction

Such a diagnosis is established in the presence of clinical and (or) laboratory (changes in enzyme activity) and electrocardiographic data indicating the occurrence of a necrosis focus in the myocardium, large or small. If, in the event of a heart attack, the patient is not hospitalized in the ICU as soon as possible, severe complications may develop, and the likelihood of death is high.

Large focal (transmural) myocardial infarction is justified by pathognomonic ECG changes or a specific increase in the activity of enzymes in the blood serum (certain fractions of creatine phosphokinase, lactate dehydrogenase, etc.) even with an atypical clinical picture.

The listed enzymes are enzymes of redox reactions. Under normal conditions, they are found only inside the cell. If the cell is destroyed (for example, with necrosis), then these enzymes are released and determined in the laboratory. An increase in the concentration of these enzymes in the blood during myocardial infarction is called the resorption-necrotic syndrome.

Diagnosis small focal myocardial infarction is set when changes in the ST segment or T wave develop in dynamics without pathological changes in the QRS complex, but in the presence of typical changes in enzyme activity.

Postinfarction cardiosclerosis

An indication of postinfarction cardiosclerosis as a complication of ischemic heart disease is introduced into the diagnosis no earlier than 2 months after the onset of myocardial infarction. The diagnosis of postinfarction cardiosclerosis as an independent clinical form of ischemic heart disease is established if angina pectoris and other forms of ischemic heart disease stipulated by the classification are absent in the patient, but there are clinical and electrocardiographic signs of focal myocardial sclerosis (stable rhythm disturbances, conduction, chronic heart failure, signs of cicatricial changes in the myocardium on ECG). If in the long-term period of the patient's examination there are no electrocardiographic signs of a previous infarction, then the diagnosis can be justified by the data of medical documentation relating to the period of acute myocardial infarction. The diagnosis indicates the presence of chronic heart aneurysm, internal myocardial ruptures, dysfunction of the papillary muscles of the heart, intracardiac thrombosis, the nature of conduction and heart rhythm disturbances, the form and stage of heart failure is determined.

Arrhythmic form

Arrhythmias of the heart or signs of left ventricular heart failure (in the form of attacks of shortness of breath, cardiac asthma, pulmonary edema) occur as equivalents of bouts of exertional angina or spontaneous angina pectoris. The diagnosis of these forms is difficult and is finally formed on the basis of the totality of the results of electrocardiographic studies in samples with exercise or with monitoring observation and the data of selective coronary angiography.

Diagnostics

Clinical symptoms

Complaints

Irradiation of pain in coronary artery disease. The intensity of the color indicates the frequency of occurrence of irradiation in this area.

The most typical complaints in coronary heart disease are:

• chest pain related to physical activity or stressful situations
• dyspnea
• Interruptions in the work of the heart, a feeling of rhythm disturbance, weakness,
• Signs of heart failure such as edema starting in the lower extremities, forced sitting position.

Anamnesis

From the history data, the duration and nature of pain, shortness of breath or arrhythmias, their relationship with physical activity, the amount of physical activity that the patient can withstand without an attack, the effectiveness of various drugs in the event of an attack (in particular, the effectiveness of nitroglycerin) are of great importance. It is important to find out if there are risk factors.

Physical examination

Physical examination may reveal signs of heart failure (moist rales and crepitus in the lower parts of the lungs, "cardiac" edema, hepatomegaly - an enlarged liver). There are no objective symptoms characteristic of ischemic heart disease that do not require laboratory or instrumental examination. Any suspicion of coronary artery disease requires electrocardiography.

Electrocardiography

ECG is an indirect research method, that is, it does not say how many myocardial cells have died, but it allows us to evaluate some of the myocardial functions (automatism and, with some assumptions, conduction). For the diagnosis of most pathological conditions of the myocardium (cardiomyopathy, hypertrophy and some other diseases), the ECG has a secondary, auxiliary function.

Some signs of acute myocardial infarction

A characteristic sign of a macrofocal myocardial infarction (transmural) is the presence of a pathological Q wave on the ECG.

1. in lead I:
   • there is a pathological Q wave (> 0.03 s, the amplitude exceeds 1/3 of the R wave amplitude)
   • there is a negative T wave.
2. there is a pathological Q wave in lead II (> 0.03 s, the amplitude exceeds 1/4 of the R-wave)
3. there is a pathological Q wave in lead III (> 0.03 s, the amplitude exceeds 1/2 of the R wave)
4. there is a QS or QR wave in leads V1, V2, V3 and the T wave is negative.
5. in leads V4, V5, V6 there is a pathological Q wave (> 0.04 s) and a negative T wave.

The T wave allows you to determine the stage of the process in dynamics. For example, in lead II: in the acute stage of myocardial infarction - it is sharply positive (Purdy's curve, "cat's back"), in the acute stage it is negative (usually with a smaller amplitude), in the subacute stage and the stage of scarring, the T-wave rises to the isoline, but often does not reach it (if there is a large-focal heart attack). An abnormal Q wave and a weakly expressed negative T wave, which do not change for several days, are an electrocardiographic sign of a scar in the myocardial tissue.

ECG data are an objective instrumental criterion for the presence of myocardial infarction, the duration of the injury, and its localization.

Echocardiography

The essence of the method consists in irradiating tissues with ultrasound pulses of a fixed frequency and receiving a reflected signal. Based on the magnitude of the reflection, a picture of the density of the tissues through which the pulse passed is formed. Modern devices carry out the output of graphic information in real time, it is also possible to assess the blood flow due to the Doppler effect.

With ischemic heart disease, echocardiography allows you to assess the state of the myocardium, the safety of the valvular apparatus of the heart, its contractile activity.

Laboratory indicators

IHD combines many heart diseases, and, accordingly, the biochemical changes arising in the course of their development are different. The following changes may evolve.

Troponin and creatine kinase at different periods of the course of myocardial infarction.

Changes characteristic of myocardial infarction

Myocardial infarction is characterized by an increase in concentrations specific proteins. Among them:

• creatine phosphokinase(first 4-8 hours);
• troponin-I (7-10 days);
• troponin-T (10-14 days);
• lactate dehydrogenase;
• aminotransferase;
• myoglobin (first day).

All of these proteins are contained only inside the cell. With the massive destruction of cells, these proteins enter the bloodstream and are determined in the laboratory. This phenomenon is called the resorption-necrotic syndrome.

Currently, in Russia, a significant part of medical institutions do not have equipment and materials for determining the level of troponins. This analysis is often carried out by patients in private centers on a commercial basis (with the consent of the patient to expand the volume of research).

Nonspecific reactions to myocardial injury include:

• neutrophilic leukocytosis (lasts 3-7 days) - as a manifestation of inflammation in response to necrotic changes;
• increased ESR (1-2 weeks) - as a reflection of changes in the quantitative ratio between protein fractions, which also occurs, mainly due to the development of inflammation.
• Increased ALT AST. (nonspecific markers of cytolysis)

Changes characteristic of atherosclerosis

To diagnose atherosclerosis, data is required on the following indicators:

• concentration of triglycerides;
• total cholesterol;
• high density lipoprotein cholesterol (antiatherogenic);
• low-density lipoprotein cholesterol (considered atherogenic);
• concentration apolipoprotein A1 (responsible for removing excess cholesterol from tissues);
• concentration apolipoprotein B (responsible for the delivery of cholesterol to tissues);
• atherogenic index.

Functional tests

Load test.

Functional tests are, as a rule, various types of physical activity, accompanied by the registration of the parameters of the heart, as a rule, an ECG. The main point of conducting tests is to identify pathology in the early stages, when at rest the characteristic changes do not yet develop, but with a load, something is already bothering a person. Exercise tests are used for differential diagnosis and exercise tolerance.

The load can be given in various ways. Among them are an exercise bike, a treadmill, a step test, walking a fixed distance, climbing stairs. The disadvantage of functional tests is their lack of information in case of pronounced disorders in the myocardium (due to the impossibility of performing the volume of physical activity required by patients to obtain reliable results).

Other instrumental methods

Contrast angiography of the myocardium

Angiography of the right coronary artery of a patient with transmural myocardial infarction.

Contrast angiography of the myocardium is a method based on the introduction of a radiopaque substance into the vascular bed, followed by exposure of the myocardium to X-ray radiation. Thus, the vessels of the myocardium are contrasted, which makes it possible to determine their patency, the safety of the lumen, the degree of occlusion.

The method is used as a rule when deciding the need for surgical intervention. This study is not completely safe, the development of allergic reactions to the contrast components is possible, which is fraught with serious complications (up to anaphylactic shock).

Intraesophageal electrocardiography

It is an auxiliary method and allows you to assess the presence or absence of additional foci of excitation that are not recorded in the standard leads.

The technique consists in the introduction of an active electrode into the esophageal cavity. The method allows a detailed assessment of the electrical activity of the atria and the atrioventricular junction.

Holter monitoring

It is a method of recording an ECG during the day, designed to identify periodically arising violations of the heart. Allows to correlate the clinic with ECG data.

ECG recording is carried out using a special portable device - Holter monitor which the patient wears during the day (on a belt over his shoulder or on a belt). During the study, the patient leads his normal life, noting in a special diary the time and circumstances of the occurrence of unpleasant symptoms from the heart. Upon completion of monitoring, the data is transferred, as a rule, to a computer, where it is then processed. Some monitors have the ability to directly print information from memory to the cardiograph tape.

Treatment

Treatment of coronary heart disease primarily depends on the clinical form. For example, although some general principles of treatment are used for angina pectoris and myocardial infarction, nevertheless, the tactics of treatment, the selection of the mode of activity and specific drugs can be radically different. However, there are some general directions that are important for all forms of coronary artery disease.

Limiting physical activity

With physical exertion, the load on the myocardium increases, and as a result, the myocardial demand for oxygen and nutrients. If the blood supply to the myocardium is disturbed, this need is not satisfied, which actually leads to manifestations of ischemic heart disease. Therefore, the most important component of the treatment of any form of ischemic heart disease is the limitation of physical activity and its gradual increase during rehabilitation.

Diet

With ischemic heart disease, in order to reduce the load on the myocardium in the diet, the intake of water and sodium chloride (table salt) is limited. In addition, given the importance of atherosclerosis in the pathogenesis of ischemic heart disease, much attention is paid to limiting the products that contribute to the progression of atherosclerosis. An important component of the treatment of coronary artery disease is the fight against obesity as a risk factor.

The following food groups should be limited or, if possible, discarded.

• Animal fats (lard, butter, fatty meats)
• Fried and smoked food.
• Foods containing a large amount of salt (salted cabbage, salted fish, etc.)
• Limit high-calorie food intake, especially fast-absorbing carbohydrates. (chocolate, sweets, cakes, pastry).

For the correction of body weight, it is especially important to monitor the ratio of energy received with food eaten, and energy expenditure as a result of the body's activity. For stable weight loss, a deficit should be at least 300 calories daily. On average, a person not engaged in physical work spends 2000-2500 kilocalories per day.

Pharmacotherapy for ischemic heart disease

There are a number of groups of drugs that can be indicated for use in one form or another of ischemic heart disease. In the USA, there is a formula for the treatment of coronary artery disease: "A-B-C". It involves the use of a triad of drugs, namely antiplatelet agents, β-blockers and cholesterol-lowering drugs.

Also, in the presence of concomitant hypertension, it is necessary to ensure the achievement of target blood pressure levels.

Antiplatelet agents (A)

Antiaggregates prevent the aggregation of platelets and erythrocytes, reduce their ability to adhere and adhere to the vascular endothelium. Antiplatelet agents facilitate the deformation of erythrocytes when passing through the capillaries, improve blood flow.

• Aspirin - taken once a day at a dose of 100 mg, if you suspect the development of myocardial infarction, a single dose can reach 500 mg.
• Clopidogrel - taken 1 time per day, 1 tablet 75 mg. Mandatory admission within 9 months after performing endovascular interventions and CABG.

β-blockers (B)

Due to the action on β-arenoreceptors adrenergic blockers reduce heart rate and, as a result, myocardial oxygen consumption. Independent randomized studies confirm an increase in life expectancy with the use of β-blockers and a decrease in the frequency of cardiovascular events, including repeated ones. It is currently impractical to use the drug atenolol, as it does not improve the prognosis according to randomized trials. β-blockers are contraindicated in concomitant pulmonary pathology, bronchial asthma, COPD. The following are the most popular β-blockers with proven prognosis-enhancing properties in coronary artery disease.

• Metoprolol (Betalok Zok, Betalok, Egilok, Metocard, Vasokardin);
• bisoprolol (Concor, Coronal, Bisogamma, Biprol);
• carvedilol (Dilatrend, Talliton, Coriol).

Statins and Fibrates (C)

Cholesterol-lowering drugs are used to reduce the rate of development of existing atherosclerotic plaques and prevent the emergence of new ones. Proven to have a positive effect on life expectancy, these drugs also reduce the frequency and severity of cardiovascular events. The target cholesterol level in patients with coronary artery disease should be lower than in those without coronary artery disease, and equal to 4.5 mmol / l. The target level of LDL in patients with coronary artery disease is 2.5 mmol / L.

• lovastatin;
• simvastatin;
• atorvastatin;
• rosuvastatin (the only drug that reliably reduces the size of atherosclerotic plaque);

Fibrates. They belong to a class of drugs that increase the antiatherogenic fraction of HDL, with a decrease in which mortality from coronary heart disease increases. They are used to treat dyslipidemia IIa, IIb, III, IV, V. They differ from statins in that they mainly reduce triglycerides (VLDL) and can increase the HDL fraction. Statins predominantly lower LDL and have no significant effect on VLDL and HDL. Therefore, for the most effective treatment of macrovascular complications, a combination of statins and fibrates is required. When using fenofibrate, mortality from coronary heart disease is reduced by 25%. Of the fibrates, only fenofibrate is safely combined with all classes of statins (FDA).

• fenofibrate

Other classes: omega-3 polyunsaturated fatty acids (Omacor). In IHD, they are used to restore the phospholipid layer of the cardiomyocyte membrane. Restoring the structure of the cardiomyocyte membrane, Omakor restores the basic (vital) functions of heart cells - conduction and contractility, which were impaired as a result of myocardial ischemia.

• Omakor

Nitrates

There are nitrates for injection.

The drugs in this group are derivatives of glycerol, triglycerides, diglycerides and monoglycerides. The mechanism of action consists in the influence of the nitro group (NO) on the contractile activity of vascular smooth muscles. Nitrates predominantly act on the venous wall, reducing the preload on the myocardium (by dilating the vessels of the venous bed and depositing blood). A side effect of nitrates is lower blood pressure and headaches. It is not recommended to use nitrates at blood pressure below 100/60 mm Hg. Art. In addition, it is currently reliably known that taking nitrates does not improve the prognosis of patients with coronary artery disease, that is, does not lead to an increase in survival, and is currently used as a drug for relieving symptoms of angina pectoris. Intravenous drip of nitroglycerin allows you to effectively combat the symptoms of angina pectoris, mainly against the background of high blood pressure numbers.

Nitrates exist in both injectable and tablet forms.

• nitroglycerine;
• isosorbide mononitrate.

Anticoagulants

Anticoagulants inhibit the appearance of fibrin filaments, they prevent the formation of blood clots, help stop the growth of blood clots that have already arisen, and enhance the effect on blood clots of endogenous enzymes that destroy fibrin.

• Heparin (the mechanism of action is due to its ability to specifically bind to antithrombin III, which sharply increases the inhibitory effect of the latter in relation to thrombin. As a result, the blood clots more slowly).

Heparin is injected under the skin of the abdomen or intravenously using an infusion pump. Myocardial infarction is an indication for the appointment of heparin prophylaxis of blood clots, heparin is prescribed in a dose of 12,500 IU, injected under the skin of the abdomen daily for 5-7 days. In the ICU, heparin is administered to the patient using an infusion pump. An instrumental criterion for the appointment of heparin is the presence of depression of the S-T segment on the ECG, which indicates an acute process. This symptom is important in terms of differential diagnosis, for example, in cases where the patient has ECG signs of previous heart attacks.

Diuretics

Diuretics are designed to reduce the load on the myocardium by reducing the volume of circulating blood due to the accelerated elimination of fluid from the body.

Loopback

the drug "Furosemide" in tablet form.

Loop diuretics reduce the reabsorption of Na +, K +, Cl - in the thick ascending part of Henle's loop, thereby reducing the reabsorption (reabsorption) of water. They have a fairly pronounced rapid action, as a rule, they are used as emergency drugs (for the implementation of forced diuresis).

The most common drug in this group is furosemide (lasix). Available in injectable and tablet forms.

Thiazide

Thiazide diuretics are a Ca 2+ sparing diuretic. By reducing the reabsorption of Na + and Cl - in the thick segment of the ascending part of the loop of Henle and the initial part of the distal tubule of the nephron, thiazide drugs reduce reabsorption of urine... With the systematic use of drugs of this group, the risk of cardiovascular complications decreases in the presence of concomitant hypertension.

• hypothiazide;
• indapamide.

Angiotensin converting enzyme antagonists

By acting on the angiotensin-converting enzyme (ACE), this group of drugs blocks the formation of angiotensin II from angiotensin I, thus preventing the realization of the effects of angiotensin II, that is, leveling vasospasm. This ensures that the target blood pressure numbers are maintained. Drugs in this group have a nephro- and cardioprotective effect.

• Enalapril;
• lisinopril;
• captopril.

Antiarrhythmic drugs

The drug "Amiodarone" is available in tablet form.

• Amiodarone belongs to group III antiarrhythmic drugs, has a complex antiarrhythmic effect. This drug acts on Na + and K + channels of cardiomyocytes, and also blocks α- and β-adrenergic receptors. Thus, amiodarone has antianginal and antiarrhythmic effects. According to randomized clinical trials, the drug increases the life expectancy of patients who regularly take it. When taking tablet forms of amiodarone, the clinical effect is observed after about 2-3 days. The maximum effect is achieved after 8-12 weeks. This is due to the long half-life of the drug (2-3 months). In this regard, this drug is used for the prevention of arrhythmias and is not an emergency aid.

Taking into account these properties of the drug, the following scheme of its use is recommended. During the saturation period (the first 7-15 days), amiodarone is prescribed in a daily dose of 10 mg / kg of the patient's weight in 2-3 doses. With the onset of a persistent antiarrhythmic effect, confirmed by the results of daily ECG monitoring, the dose is gradually reduced by 200 mg every 5 days until a maintenance dose of 200 mg per day is reached.

Other groups of drugs

• Ethylmethylhydroxypyridine

The drug "Mexidol" in tablet form.

Metabolic cytoprotector, antioxidant antihypoxant, which has a complex effect on the key links in the pathogenesis of cardiovascular disease: antiatherosclerotic, antiischemic, membrane protective. In theory, ethylmethylhydroxypyridine succinate has a significant beneficial effect, but there are currently no data on its clinical efficacy based on independent, randomized, placebo-controlled trials.

• Mexicor;
• coronater;
• trimetazidine.

Antibiotic use for coronary artery disease

There are results of clinical observations of the comparative effectiveness of two different courses of antibiotics and placebo in patients admitted to the hospital with either acute myocardial infarction or unstable angina pectoris. Studies have shown the effectiveness of a number of antibiotics in the treatment of coronary artery disease. The effectiveness of this type of therapy is not pathogenetically substantiated, and this technique is not included in the standards for the treatment of coronary artery disease.

Endovascular coronary angioplasty

The use of endovascular (translucent, transluminal) interventions is developing ( coronary angioplasty) with various forms of ischemic heart disease. Such interventions include balloon angioplasty and stenting under the control of coronary angiography. In this case, the instruments are introduced through one of the large arteries (in most cases, femoral artery), and the procedure is performed under fluoroscopy control. In many cases, such interventions help prevent the development or progression of myocardial infarction and avoid open surgery.

This area of ​​treatment of ischemic heart disease is dealt with by a separate area of ​​cardiology - interventional cardiology.

Surgery

Coronary artery bypass grafting is performed.

With certain parameters of coronary heart disease, there are indications for coronary artery bypass grafting - an operation in which the blood supply to the myocardium is improved by connecting the coronary vessels below the site of their lesion with external vessels. Most famous coronary artery bypass grafting(CABG), in which the aorta is connected to the segments of the coronary arteries. For this, they are often used as shunts. autografts(usually great saphenous vein).

It is also possible to use balloon dilatation of vessels. In this operation, the manipulator is inserted into the coronary vessels through the puncture of the artery (usually of the femoral or radial), and the vessel lumen is expanded by means of a balloon filled with a contrast agent; the operation is, in fact, bougienage of the coronary vessels. Currently, "pure" balloon angioplasty without subsequent stent implantation is practically not used due to its low efficiency in the long-term period.

Other non-drug treatments

Hirudotherapy

Hirudotherapy is a method of treatment based on the use of the antiplatelet properties of leech saliva. This method is an alternative and has not been clinically tested for compliance with the requirements of evidence-based medicine. Currently in Russia it is used relatively rarely, is not included in the standards of medical care for coronary artery disease, it is used, as a rule, at the request of patients. The potential beneficial effects of this method are in the prevention of blood clots. It is worth noting that when treated according to approved standards, this task will be accomplished with the help of heparin prophylaxis.

Shock wave therapy

Exposure to low power shock waves leads to myocardial revascularization.

An extracorporeal source of a focused acoustic wave allows a remote effect on the heart, causing "therapeutic angiogenesis" (vascular formation) in the zone of myocardial ischemia. The effect of SWT has a double effect - short-term and long-term. First, the vessels dilate and blood flow improves. But the most important thing begins later - new vessels appear in the affected area, which provide long-term improvement.

Low-intensity shock waves induce shear stress in the vascular wall. This stimulates the release of vascular growth factors, triggering the growth of new vessels that feed the heart, improving myocardial microcirculation and reducing the symptoms of angina pectoris. Theoretically, the results of such treatment are a decrease in the functional class of angina pectoris, an increase in exercise tolerance, a decrease in the frequency of attacks and the need for drugs.

However, it should be noted that at present there have been no adequate independent multicenter randomized studies evaluating the effectiveness of this technique. Studies cited as evidence of the effectiveness of this technique are usually carried out by the manufacturing companies themselves. Or do not meet the criteria of evidence-based medicine.

This method is not widely used in Russia due to the dubious efficiency, high cost of equipment, and the lack of appropriate specialists. In 2008, this method was not included in the standard of medical care for coronary artery disease, and these manipulations were performed on a contractual commercial basis, or in some cases under voluntary medical insurance contracts.

Use of stem cells

When using stem cells, those performing the procedure expect that the pluripotent stem cells introduced into the patient's body will differentiate into missing myocardial cells or vascular adventitia. It should be noted that stem cells actually have this ability, but at present the level of modern technologies does not allow differentiating a pluripotent cell into the tissue we need. The cell itself makes the choice of the pathway of differentiation - and often not the one that is needed for the treatment of coronary artery disease.

This method of treatment is promising, but has not yet been clinically tested and does not meet the criteria of evidence-based medicine. It takes years of research and development to deliver the benefits that patients expect from pluripotent stem cells.

Currently, this method of treatment is not used in official medicine and is not included in the standard of care for coronary artery disease.

Quantum therapy for ischemic heart disease

It is a therapy by exposure to laser radiation. The effectiveness of this method has not been proven, an independent clinical study has not been conducted. Equipment manufacturers claim that quantum therapy is effective for almost all patients. Drug manufacturers report studies that have shown the low efficacy of quantum therapy.

In 2008, this method is not included in the standards of medical care for coronary artery disease, it is carried out mainly at the expense of patients. It is impossible to assert the effectiveness of this method without an independent, open, randomized trial.

Genetics

• SOD3 - R213G polymorphism is associated with an increased risk of disease.

Forecast

The prognosis is conditionally unfavorable, the disease is chronic and steadily progressive, treatment only stops or significantly slows down its development, but does not reverse the disease.

Chronic heart disease has recently been diagnosed with increasing frequency, and not only among elderly patients. The occurrence of these pathologies is influenced by many factors: smoking, frequent stress, lack of physical activity and others. Unfortunately, only timely seeking help from a doctor can avoid the development of negative consequences.

International Classification of Diseases (ICD 10)

Heart diseases are classified as the ninth class of pathologies of the circulatory system. It should be noted that this classification is a specially developed document that is used as the leading statistical basis in health care. The ICD is periodically reviewed under the guidance of WHO.

The following pathologies also belong to the ninth class: ischemia (IHD), chronic rheumatic heart disease, cerebrovascular pathologies, lesions of veins / lymph nodes, and others.

As early as the 20th century, mortality rates from diseases have changed. If earlier various kinds of infections acted as the cause of death, now they have been replaced by cardiovascular pathologies, injuries and oncological ailments. For example, chronic rheumatic heart disease takes the next place after arterial hypertension, stroke and coronary heart disease. However, in this article we will talk in more detail about the latter pathology, its causes of development, clinical forms and modern methods of treatment.

general information

Ischemic heart disease is a number of ailments characterized by insufficient oxygen supply to the main muscle of the body. The development of this pathology is based on the constant process of deposition of atherosclerotic plaques on the walls of the coronary vessels. They consistently reduce the lumen of the arteries, thereby provoking problems with the flow of blood to the heart and its normal functioning. Atherosclerotic deposits are also dangerous because they can self-destruct over time. Their fragments, along with blood, are carried throughout the body. This is how the well-known blood clots are formed.

In developed countries today ischemic heart disease is becoming the main cause of death and disability of the population. This pathology accounts for about 30% of deaths. According to available information, the disease is diagnosed in one in three women and almost half of men. This difference is very easily explained. Female hormones are a kind of protection against atherosclerotic vascular lesions. However, with a change in hormonal levels, which is most often observed during menopause, the likelihood of developing an ailment in the fair sex increases several times.

Classification

A group of WHO specialists back in 1979 presented the classification of coronary heart disease. Symptoms, treatment and prognosis for each type has its own distinctive characteristics.

• Asymptomatic form. Oxygen deficiency in no way affects the human condition.
• Angina pectoris (stable, unstable, spontaneous). This form manifests itself in the form of chest pain after physical exertion, eating or a stressful situation.
• Arrhythmic form. Accompanied by repeated interruptions in the heart rhythm, it often turns into a chronic stage.
• The so-called coronary death. Complete cardiac arrest due to a sharp decrease in the level of blood supplied to the organ. This pathology occurs due to blockage of a large artery, which very often accompanies heart disease.
• Myocardial infarction. It is characterized by the loss of a portion of the heart muscle after prolonged oxygen starvation.

In angina pectoris, the following subclasses are distinguished:

• FC-1. Painful discomfort appears in response to serious physical exertion.
• FC-2. Attacks appear when walking, after the next meal.
• FC-3. Pain occurs only after minor exertion.
• FC-4. It manifests itself with the most insignificant emotional upheavals.

Causes

The most common disease leading to a sequential decrease in the lumen of blood vessels is atherosclerotic heart disease. With this pathology, the vessels from the inside are covered with a layer of fatty fragments, which subsequently harden. As a result, there is a difficulty in blood flow directly to the heart muscle itself.

Another cause of ischemic heart disease is the so-called arterial hypertension. A decrease in blood flow initially entails the appearance of pain during physical exertion (the required amount of oxygen is not supplied to the myocardium due to obstacles in the path of blood flow), and then discomfort accompanies the person even in a calm state.

Atherosclerosis is very often the basis for the development of other pathological reactions. Among them, the most common are the following: spasm of the coronary arteries, the formation of blood clots, problems with diastolic-systolic function.

Factors contributing to the formation of ischemic heart disease

• Hereditary predisposition.
• High cholesterol levels.
• Bad habits (smoking, alcohol abuse). According to the available information, smoking cigarettes increases the risk of various forms of coronary heart disease by 6 times.
• High blood pressure.
• Obesity.
• Diabetes.
• The complete absence of sports activities, sedentary work.
• Elderly age (many diseases of the heart and blood vessels develop after 50 years).
• Excessive consumption of fatty foods.
• Frequent stress. They, of course, increase the load on the heart, increase blood pressure, which impairs the delivery of oxygen to the main organ.

The causes and speed of ischemia formation, its severity and duration, the initial state of health - all these factors predetermine the appearance of one or another form of coronary heart disease.

Symptoms

Treatment of this pathology is prescribed only after the appearance of its first signs, as well as a complete diagnostic examination. What are the symptoms of ischemic heart disease?

All of the above factors are clear signs that the patient has coronary artery disease. Symptoms, of course, in each case can vary and differ in intensity. What are the characteristics of certain forms of ischemic heart disease?

Deterioration of blood flow in the coronary vessels during the final closure of the lumen with a thrombus can lead to acute ischemia, in other words, to myocardial infarction, and with its partial closure - to chronic oxygen starvation of the heart, and this is angina pectoris. Both acute and chronic ischemia are accompanied by chest pain.

With a heart attack, this kind of discomfort occurs suddenly. These are usually short-term seizures. Gradually, their intensity increases, literally in an hour the pain becomes unbearable.

With angina pectoris, the main symptom is chest discomfort that occurs during intense physical or emotional stress. The duration of the attack itself, as a rule, does not exceed. At the initial stage of the development of the pathology, the patient feels pain in the sternum, as the disease develops, the intensity increases. During the next attack, there is difficulty breathing, fear. Patients stop moving and literally freeze until the attack stops completely.

In addition to the common forms of angina pectoris, there are varieties of the course of ischemic heart disease in which the symptoms described above are either implicitly expressed or completely absent. Instead of severe pain, patients may notice attacks of suffocation, heartburn, weakness in the left arm.

Sometimes painful discomfort is localized exclusively in the right half of the chest. In some cases, the ailment makes itself felt during reading or during normal household chores, but does not appear during sports or emotional stress. As a rule, in this case we are talking about Prinzmetal's angina. For this type of pathology, according to experts, an individual cyclical nature of the occurrence of attacks is characteristic, they are formed exclusively at a certain time of the day, but most often at night.

Recently, the so-called painless ischemic heart disease has also become more common. Its treatment, as a rule, is complicated by the fact that it is not possible to carry out the necessary diagnostic operations in a timely manner. In this kind of situation, therapy is prescribed already at a later stage.

Diagnostics

You should not ignore such a pathology as coronary heart disease. The symptoms described in this article should alert you and become a reason for everyone to consult a specialist.

At the appointment, the doctor first of all collects a complete history of the patient. He can ask a number of clarifying questions (when the pains appeared, their nature and approximate localization, are there any such pathologies in the closest relatives, etc.). A diagnostic examination is mandatory, which includes the following procedures:

To finally determine the causes of ischemic heart disease, an additional study of the level of cholesterol, triglycerides, lipoproteins, and blood sugar may be required.

What should be the therapy?

The tactics of dealing with various clinical forms of the disease has its own characteristics. However, the main directions that are actively used in modern medicine should be outlined:

• Drug-free treatment.
• Drug therapy.
• Coronary artery bypass grafting.
• Help of endovascular techniques (coronary angioplasty).

Non-drug therapy means lifestyle and nutritional adjustments. For any manifestations of ischemic heart disease, a strict limitation of the usual mode of activity is shown, since during physical exertion, an increase in myocardial oxygen demand is often observed. Her dissatisfaction, as a rule, provokes coronary heart disease of this nature. That is why, in any clinical forms of coronary artery disease, the patient's activity is limited, but during the rehabilitation period it gradually expands.

Diet for illness means limiting water and salt intake to reduce pressure on the heart muscle. If the cause of the pathology is hidden in obesity, or atherosclerotic heart disease is to blame, a low-fat diet is recommended. It is necessary to limit the consumption of the following products: lard, fatty meats, smoked meats, baked goods, chocolate, baked goods. To maintain a healthy weight, it is important to constantly monitor the balance of consumed and consumed energy.

Drug therapy is based on taking the following groups of drugs:

• Antiplatelet agents (Aspirin, Trombopol, Clopidogrel). These drugs are responsible for reducing blood clotting.
• Anti-ischemic drugs (Betolok, Metocard, Coronal).
• ACE inhibitors for lowering blood pressure ("Enalapril", "Captopril").
• Cholesterol-lowering drugs responsible for lowering cholesterol levels (Lovastatin, Rosuvastatin).

Some patients are additionally prescribed diuretics (Furosemide) and antiarrhythmics (Amiodarone). Sometimes even competent drug therapy does not help in the fight against such pathologies as coronary heart disease. Treatment through surgery is the only sure way out in this situation.

Coronary artery bypass grafting is generally recommended. Such an operation is resorted to in order to provide the heart with oxygen and restore its normal functioning. The patient's own blood vessels are used as a new pathway for blood flow, travel directly to the heart and then sutured. This operation relieves the patient of possible attacks of angina pectoris, reduces the risk of sudden cardiac death and the development of a heart attack.

Coronary angioplasty is a minimally invasive technique. During this operation, a special stent frame is installed into the narrowed vessel, which holds the vessel lumen sufficient for normal blood flow.

Other methods of treatment

• Hirudotherapy. This method of treatment is based on the use of the antiplatelet properties of leech saliva. Currently, on the territory of our country, this approach is used extremely rarely and only at the request of the patients themselves. The only positive result of hirudotherapy is the prevention of blood clots.
• Use of stem cells. It is assumed that after the introduction of stem cells into the body, they differentiate into the missing components of the myocardium. Stem cells do have this ability, but they can transform into any other cells in the body. Despite the positive results of this method of treatment, it is not used in practice today. In many countries, this technique is experimental in nature and is not included in the accepted standards for caring for patients with coronary artery disease.

Possible complications

The most dangerous complication of various forms of ischemic heart disease is the occurrence of an attack of acute insufficiency, which often leads to death.

In this condition, death occurs instantly or within six hours after the immediate onset of a pain attack. According to experts, 70% of deaths are caused by this complication in the presence of predisposing factors (alcohol intake, heart rhythm disturbances, myocardial hypertrophy).

The risk group also includes patients who do not receive competent therapy with such a diagnosis.

Other equally dangerous complications of coronary artery disease include the following: myocardial infarction (in 60% of cases, the problem is preceded by another pathology called angina pectoris), heart failure.

How to prevent the development of the disease?

What should be the prevention? Heart disease is mostly caused by poor nutrition. That is why experts strongly recommend, first of all, to completely revise your usual diet. It should be as balanced as possible and consist exclusively of "healthy" foods. Food sources of cholesterol and saturated fats (fatty meats, sausages, lard, dumplings, mayonnaise) should be excluded from the diet. Fresh fruits, vegetables, herbs, seafood, nuts, mushrooms, cereals, legumes are all components of a healthy diet. They are safe for patients with primary signs of coronary artery disease.

The human heart is a rather complex organ that requires appropriate attention. As you know, his work is significantly impaired if a person is overweight. That is why, in order to prevent the development of ischemic heart disease, it is recommended to keep body weight under constant control. You should periodically arrange fasting days and monitor the calorie intake.

Doctors, without exception, recommend regular physical activity. There is no need to go to the gym every day or start doing serious sports. Hiking, yoga, remedial gymnastics - such simple activities can dramatically improve health and prevent coronary heart disease. Disease prevention also means reducing stress and eliminating bad habits altogether. As you know, it is the latter that not only contribute to the development of ischemic heart disease, but also significantly complicate the quality of life of a person and his immediate environment. When it comes to stress, it is extremely difficult to avoid it in everyday life. In this kind of situation, experts recommend changing your attitude to everything that happens, starting to engage in breathing exercises.

Conclusion

In this article, we have described in as much detail as possible what constitutes coronary heart disease. Symptoms, treatment and causes of this pathology should not be ignored, since they are all interconnected. Timely access to a doctor and full compliance with all his recommendations allow you to control ischemic heart disease, as well as prevent the occurrence of various kinds of complications. Be healthy!

Ischemic heart disease - an abbreviation that includes heart pathologies, implying a partial or complete cessation of blood flow to the main organ of the human body.

Cessation of blood supply occurs due to various problems, but for any reason, ischemia remains one of the main conditions fraught with death.

Factors provoking interruptions in blood circulation occur singly or in combination:

• an increase in the number of low-density lipoproteins in the blood, which increases the likelihood of ischemia five times;
• against the background of increased blood pressure, the risk of ischemia increases according to the increase in pressure;
• often acute myocardial ischemiaprovoked by smoking - the more cigarettes a man in the age of 30-60 smokes, the greater the risk of coronary artery disease;
• with overweight and low mobility can face ischemia;

Forms of ischemia

All three known forms of ischemic disease are dangerous and without timely treatment it will not be possible to save a person:

• sudden coronary death. It is characterized by an acute manifestation of ischemia and death within 6 hours. According to doctors, the reason is the fragmentation of the work of the ventricles of the heart. Pathology is recorded when there are no other deadly diseases. In this case, the ECG does not provide the necessary information, although in most cases they do not have time to do it. Autopsy reveals extensive atherosclerosis that has affected all blood vessels. Thrombi are found in the vessels of the myocardium in half of the dead people;
• acute focal myocardial dystrophy. After the development of ischemia, this form occurs 6-18 hours later. It can be identified using an ECG. Within 12 hours, the damaged heart muscle can release enzymes into the bloodstream. The main cause of death is heart failure, fibrillation, lack of bioelectric activity;
• myocardial infarction. Such disease characterized by necrosis of the heart muscle. After acute ischemia, heart attack can reveal after a day. Pathology develops in stages - first, tissue necrosis occurs, then scarring. A heart attack is subdivided into forms, taking into account the localization and the time of detection. The consequences of this form of ischemic heart disease are: aneurysm, fibrillation, heart failure. All of these conditions can lead to death.

Sudden coronary death

Such a pathology is discussed when people die for no apparent reason, more precisely against the background of signs of cardiac arrest, if:

• death occurred within an hour from the onset of unpleasant symptoms;
• before the attack, the person felt stable and well;
• there are no circumstances capable of causing death (injury, strangulation, etc.).

The causes of sudden cardiac death include coronary artery disease in various manifestations - overgrowth of the heart muscle and related pathologies, fluid accumulation in the pericardium, failure of the contractile functions of the heart, pulmonary artery thrombosis, coronary artery disease, congenital malformation, intoxication, metabolic failure, etc. At risk are patients with heart failure, hypertension, smokers.

One of the factors of sudden coronary death is the difficulty of identifying the risk of pathology. Unfortunately, in 40%, death itself was a symptom of the disease. Based on the data of pathologists, a strong narrowing of the coronary arteries was revealed. The damage to the blood vessels, the thickening of their walls, and the accumulation of fatty deposits are noticeable. Often, endothelial damage, clogging of the lumen of blood vessels with blood clots are detected.

How does an attack occur? Spasm occurs in the coronary vessels. The required amount of oxygen does not enter the heart, as a result acute ischemic heart disease, which can end in sudden death. At autopsy, myocardial infarction is confirmed in 10% of cases, since its macroscopic symptoms will be noticeable only after 24 hours or more. This is the main difference between different forms of ischemic heart disease.

Doctors talk about 2 reasons from which you can die in acute ischemia:

1. the inhomogeneous work of the ventricles leads to a chaotic contraction of the muscles, which affects the blood flow until it stops;
2. cardiac arrest due to electromechanical dissociation.

An electron microscope allows you to see how 30 minutes after the onset of acute ischemia, cardiac circulation stops. After that, the heart tissue undergoes deformation within 2-3 hours, and significant deviations are revealed in the heart metabolism. This leads to electrical instability and heart rhythm disruption. According to statistics, most sudden deaths as a result of ischemia do not occur in the hospital, but where it was not possible to provide the victim with assistance in time.

An exacerbation of the condition can occur after a severe nervous shock or physical overload. Sometimes the sudden coronary death of a person catches in a dream. The harbingers of this state will be:

• pressing pain in the sternum against the background of a strong fear of death;
• shortness of breath and fatigue, poor performance and poor health a week before the exacerbation of the condition;
• when the ventricles of the heart begin to work out of tune, this will cause weakness, dizziness, noisy breathing;
• loss of consciousness occurs due to a lack of oxygen in the brain;
• the skin becomes cold and pale gray;
• pupils dilate, do not respond to stimuli;
• the pulse in the carotid artery is not palpable;
• breathing becomes convulsive and stops after about 3 minutes.

The onset of ischemia in this form requires urgent medical attention. Cardiopulmonary resuscitation should be done, improved airway patency, forced oxygen delivery to the lungs, and heart massage to maintain circulation.

Medicines for this condition are needed to relieve the pathology caused by ventricular fibrillation or rapid heartbeat. The doctor will give drugs that can affect the ionic membranes of the heart. There are several groups of drugs that differ in their spectrum of action:

• aimed at preventing disorders in the cells and tissues of the heart;
• able to weaken the tone and excessive excitability of the nervous system;
• antiarrhythmic inhibitors and blockers;
• for prophylaxis, a potassium antagonist, statins are prescribed.

If preventive measures do not give the expected result, doctors resort to surgical methods:

• pacemakers are implanted for bradyarrhythmia;
• defibrillators are implanted for ventricular fibrillation and tachycardia;
• the catheter is inserted through the blood vessels in the syndrome of excitation of the ventricles of the heart.

Myocardial dystrophy

This form of ischemic disease develops against the background of impaired metabolism and biochemical abnormalities. The condition is classified as a serious pathology, but is not considered a separate disease. Despite this, pronounced clinical manifestations make it possible to identify this particular condition, and not any other. Myocardial dystrophy is detected when violations of blood circulation are confirmed, as a result of which a pathological condition develops. Focal myocardial dystrophy often affects the elderly and athletes.

The causes of focal dystrophy of the heart muscle include heart disease (myocarditis, ischemic heart disease, cardiomyopathy), as well as pathological conditions in the body that develop as a result of hormonal disruptions, diseases of the nervous system, tonsillitis, intoxication, and blood disorders. Also, myocardial dystrophy is provoked by drug abuse, diseases of the respiratory system and thyroid gland, excessive physical activity for a long time.

Sometimes myocardial dystrophy proceeds without vivid symptoms, in other cases it manifests itself as characteristic signs of heart failure. It can be swollen joints, shortness of breath, weakness and irregular heartbeat, pain in the sternum after physical and psycho-emotional stress. If you do not provide assistance in time, the clinical picture becomes brighter, the pain spreads throughout the sternum, becomes intense. The patient's skin turns red, sweat is vigorously secreted. While drinking alcohol, tachycardia, cough, feeling of shortness of breath may develop.

With a mild degree of myocardial dystrophy, treatment in a polyclinic or in a day hospital is sufficient, hospitalization is not required. The purpose of helping the patient, first of all, is to establish the cause of the pathology.

If the failure is caused by problems of the endocrine system, then medications are prescribed that can correct their work. These are usually hormonal medications.

In case of anemia, the patient is prescribed vitamins with iron. With tonsillitis, antibiotics are used. When stress becomes the cause of muscular dystrophy, patients prescribe sedatives, and additionally prescribe cardiotropic drugs that normalize blood circulation and nourish the heart muscle. The doctor must monitor the course of treatment and the patient's condition.

Myocardial infarction

For the most part, this form of ischemic disease is considered a male problem, since it is in men that a heart attack is detected 2 times more often than in women. A heart attack is a consequence of advanced atherosclerosis, develops against the background of constant high blood pressure (hypertension). Other provoking factors are: obesity, smoking, alcohol in unlimited quantities, low physical activity. Sometimes a heart attack is only the first symptom of ischemia, and the mortality rate from it is up to 15%. You can save a person from such a pathology if you react correctly and on time. Death threatens a person in about 18 hours from the onset of acute ischemia, and this time should be spent usefully on providing adequate assistance.

The main cause of a heart attack is obstruction of the heart arteries, or rather, the coronary vessels are blocked by blood clots that form at the site of atherosclerotic accumulations. If a blood clot clogs a vessel, it abruptly stops the flow of blood to the heart, and with it, air. Without oxygen, myocardial cells cannot maintain vital activity for a long time. For about 30 minutes, the heart muscle will still be alive, after which the necrotic process begins. Cell death lasts for 3-6 hours. Based on the size of the affected area (necrosis), doctors distinguish between small-focal and large-focal infarction, and also transmural - a condition when necrosis affects the entire heart.

Treatment should be started immediately. If someone nearby is experiencing a long and severe pain in the sternum, against the background of this, the skin turns pale and sweats, the condition is fainting, then you need to immediately call an ambulance. While the doctors arrive, the patient should be given a nitroglycerin tablet under the tongue, 3-4 drops of Corvalol and chewed aspirin.

An ambulance will take the patient to the intensive care unit, where the patient will be given pain relievers, lowered blood pressure, normalized heart rate and blood flow, and removed a blood clot. If resuscitation is successful, it will be followed by a rehabilitation period, the duration of which is determined by the general condition and age of the patient.

General scheme for the treatment of ischemia

When prescribing treatment, the doctor takes into account the peculiarities of each of the clinical forms of ischemic disease, which were described above. But there are general principles of action in relation to patients with coronary artery disease:

• drug therapy;
• non-drug treatment;
• myocardial revascularization - an operation also called coronary artery bypass grafting;
• endovascular technique (angioplasty).

Non-drug therapy involves a number of measures aimed at correcting the patient's lifestyle, choosing the right diet. With different manifestations of ischemia, it is recommended to reduce physical activity, since with an increase in activity, the myocardium requires more blood and oxygen. If this need is not fully met, ischemia occurs. Therefore, for any form of the disease, it is immediately recommended to limit the load, and during the rehabilitation period, the doctor will give recommendations regarding the rate of loads and the gradual increase in their volume.

The diet for ischemic disease changes, the patient is advised to limit the intake of drinking water per day and salt food less, as this puts a strain on the heart. To slow down atherosclerosis and start fighting overweight, you need to prepare meals from a low-fat diet. It is necessary to seriously limit, and, if possible, remove from the menu the following products: animal fats (fatty meat, lard, butter), smoked meats and fried foods, fast carbohydrates (chocolate, sweets, cakes and pastries).

A balance between energy consumption and energy expenditure will help prevent weight gain. The calorie table of foods can always be kept in front of your eyes. To reduce weight to a certain level, you need to create a deficit between the calories consumed with food and the expenditure of energy reserves. This deficit for weight loss should be equal to approximately 300 kilocalories each day. An approximate figure is given for those who lead an ordinary life, in which up to 2500 kilocalories are spent on daily activities. If a person moves very little due to a state of health or elementary laziness, then he spends fewer calories, which means that he needs to create a larger deficit.

However, simple fasting will not solve the problem - this will burn muscles faster, not fats. And even if the scales show a loss of kilogram, it is leaving water and muscle tissue. Fats are lighter and go away last, if you do not move. Therefore, minimal physical activity is still needed to burn excess body fat and remove harmful lipids from the body.

As for drugs, antiplatelet agents, beta-blockers and cholesterol-lowering drugs are prescribed for ischemia. If there are no contraindications, diuretics, nitrates, anti-arrhythmia drugs and other drugs are included in the treatment regimen, taking into account the patient's condition.

If drug therapy does not give an effect and there is a risk of developing a heart attack, consultation with a cardiac surgeon and subsequent operation is necessary. CABG or coronary artery bypass grafting is performed to restore the area damaged by ischemia, such an operation is indicated for drug resistance, if the patient's condition does not change or becomes worse than it was. During the operation, an autovenous anastomosis is applied in the area between the aorta and the coronary artery below the area that is severely narrowed or blocked. Thus, it is possible to create a new channel through which blood will be delivered to the affected area. CABG is performed with extracorporeal circulation or a beating heart.

Another surgical method for the treatment of coronary artery disease is PTCA - a minimally invasive surgery, which is a percutaneous transluminal coronary angioplasty. During the operation, the narrowed vessel is expanded by introducing a balloon, then a stent is installed, which will serve as a frame to maintain a stable lumen in the blood vessel.

Prognosis for ischemia

The patient's condition after the detection and treatment of coronary artery disease depends on many factors. For example, ischemia is considered unfavorable against the background of high blood pressure, diabetes mellitus, and lipid metabolism disorders. In such severe cases, treatment can slow the progression of coronary artery disease, but not stop it.

To minimize the risk of ischemia, it is necessary to reduce the influence of adverse factors on the heart. These are well-known recommendations - to exclude smoking, not to abuse alcoholic beverages, to avoid nervous overstrain.

It is important to maintain optimal body weight, daily give the body a portion of feasible physical activity, control blood pressure and eat healthy foods. Simple recommendations can significantly change your life for the better.

Cardiovascular disease is currently the leading cause of death and disability worldwide. The leading role in the structure of mortality from cardiovascular diseases belongs to ischemic heart disease.

Ischemic heart disease (IHD) is a chronic disease that develops when there is insufficient oxygen supply to the myocardium. The main reason (in more than 90% of cases) of insufficient oxygen supply is the formation of atherosclerotic plaques in the lumen of the coronary arteries, which supply blood to the heart muscle (myocardium).

Prevalence

According to the World Health Organization (WHO), mortality from cardiovascular disease is 31% and is the most common cause of death worldwide. On the territory of the Russian Federation, this figure is 57.1%, of which more than half of all cases (28.9%) fall to the share of IHD, which in absolute terms is 385.6 people per 100 thousand of the population per year. For comparison, mortality from the same cause in the European Union is 95.9 people per 100 thousand of the population per year, which is 4 times less than in our country.

The incidence of IHD increases sharply with age: in women from 0.1-1% at the age of 45-54 to 10-15% at the age of 65-74, and in men from 2-5% at the age of 45-54 to 10 -20% aged 65-74.

Cause of development and risk factors

The main reason for the development of coronary heart disease is atherosclerotic lesions of the coronary arteries. Due to certain risk factors, cholesterol is deposited on the walls of blood vessels for a long time. Then a plaque is gradually formed from the cholesterol deposits. Atherosclerotic plaque, gradually increasing in size, disrupts the blood flow to the heart. When the plaque reaches a significant size, which causes an imbalance in the delivery and consumption of blood by the myocardium, then coronary heart disease begins to manifest itself in various forms. The main form of manifestation is angina pectoris.

IHD risk factors can be divided into modifiable and non-modifiable.

Non-modifiable risk factors are factors that we cannot influence. These include

• Floor. Male gender is a risk factor for cardiovascular disease. However, entering the climacteric period, women are deprived of the protective hormonal background, and the risk of developing adverse cardiovascular events becomes comparable to the male sex.
• Age. After age 65, the risk of cardiovascular disease increases dramatically, but not equally for everyone. If the patient has a minimum number of additional factors, then the risk of developing adverse events remains minimal.
• Heredity. A family history of cardiovascular disease should also be considered. The risk is influenced by the presence of cardiovascular diseases in the female line up to 65 years old, in the male line up to 55 years.
• Other non-modifiable risk factors. Other non-modifiable factors include ethnicity (for example, Negroids have a higher risk of stroke and chronic renal failure), geography (for example, a high incidence of stroke and coronary artery disease in Russia, Eastern Europe and the Baltic countries; low risk of coronary artery disease in China).

Modifiable risk factors are factors that can be influenced by lifestyle changes or medication. The modifiables can be divided into behavioral and physiological and metabolic.

Behavioral risk factors:

• Smoking. According to the World Health Organization, 23% of deaths from coronary artery disease are due to smoking, reducing the life expectancy of smokers aged 35-69 years, on average by 20 years. Sudden death among persons who smoke a pack of cigarettes or more during the day is observed 5 times more often than among nonsmokers.
• Eating habits and physical activity.
• Stress.

Physiological and metabolic features:

• Dyslipidemia. This term means an increase in total cholesterol, triglycerides and an imbalance between cholesterol fractions. The total cholesterol level in patients should be no higher than 5 mmol / L. The level of low-density lipoprotein (LDL) in patients who have not had myocardial infarction should not be higher than 3 mmol / L, and in persons who have had myocardial infarction, this indicator should correspond to the value< 1,8 ммоль/л. Также негативный вклад в развитие неблагоприятных сердечно-сосудистых событий вносят липопротеиды высокой плотности (ЛПВП) и триглецириды. ЛПВП должны быть выше 1,42 ммоль/л, а верхняя рекомендуемая граница для триглицеридов – 1,7 ммоль/л.
• Arterial hypertension. To reduce the risk of cardiovascular complications, it is important to achieve a blood pressure target of less than 140/90 mmHg. In patients with high and very high risk of cardiovascular complications, it is necessary to lower blood pressure to 140/90 mm Hg. and less, within 4 weeks. In the future, subject to good tolerance, it is recommended to lower blood pressure to 130/80 mm Hg. and less.
• Obesity and the nature of the distribution of body fat. Obesity is an metabolic and alimentary chronic disease, which is manifested by the excessive development of adipose tissue and progresses during the natural course. Overweight can be estimated using the formula that determines the body mass index (BMI):

BMI = body weight (kg) / height 2 (m 2). If BMI is 25 or more - an indication for weight loss.

• Diabetes. Given the high risk of developing unwanted cardiovascular events in diabetes, as well as the fact that the first myocardial infarction or cerebral stroke in patients with diabetes is more often fatal, hypoglycemic therapy is an important component of the primary prevention of unwanted cardiovascular events in patients with type II diabetes.

The SCORE scale has been developed to calculate the degree of risk. This scale calculates the 10-year risk of cardiovascular disease.

Clinical manifestations of ischemic heart disease

The most typical complaints in coronary heart disease are:

Exercise-related chest pain or stressful situations

Dyspnea

Interruptions in the work of the heart, a feeling of disturbance in the rhythm of the heart, weakness,

From the history data, the duration and nature of pain, shortness of breath or arrhythmias, their relationship with physical activity, the amount of physical activity that the patient can withstand without an attack, the effectiveness of various drugs in the event of an attack (in particular, the effectiveness of nitroglycerin) are of great importance.

With angina pectoris, the pain syndrome lasts up to 30 minutes; in the case of myocardial infarction, the pain can last for several hours.

Forms of ischemic heart disease

Diagnosis of ischemic heart disease

Diagnosis of coronary heart disease includes an assessment of the patient's complaints: the nature and localization of pain sensations, their duration, conditions of occurrence, the effect of taking nitroglycerin preparations.

An electrocardiographic study is mandatory (ECG monitoring is preferable), stress tests (bicycle ergometry, treadmill test, etc.), selective coronary angiography is the gold standard in diagnosis. Additionally, myocardial scintigraphy, computed tomography (to exclude heart defects and heart aneurysms) are used. In terms of determining prognosis and assessing the risk of cardiovascular complications - determination of cholesterol and serum lipoproteins, etc.

CHD treatment

The main goal in the treatment of chronic coronary artery disease is to reduce the oxygen demand of the heart, or to increase the delivery of oxygen. In connection with the above, the treatment of coronary artery disease can be divided into medical and surgical.

Drug treatment includes drug therapy, the main groups of drugs are beta-blockers, nitroglycerin (for the relief of acute attacks), long-acting nitrates, calcium channel blockers. For hypercholesterolemia, statins are prescribed, and small doses of acetylsalicylic acid are prescribed to prevent thrombus formation. In the presence of concomitant arterial hypertension - drugs that lower blood pressure.

In the absence of the effect of conservative therapy, surgical treatment is performed:

Prevention of ischemic heart disease

It is always easier to prevent a disease than to cure it!

Since the main role in the development of coronary heart disease is assigned to atherosclerosis, then the prevention of this disease should be aimed at combating the development of atherosclerotic lesions of the coronary arteries. It is necessary to influence the risk factors. If we cannot influence the unmodifiable factors in any way, then we direct all prevention to the modifiable factors:

Smoking cessation! Smoking is one of the main causes of atherosclerosis, arterial hypertension, coronary heart disease and stroke. Conversely, smoking cessation leads to a decrease in the risk of disease.

Weight control and adherence to dietary advice. A diet low in cholesterol and fats is prescribed: the use of fatty meats, fatty dairy products, rich broths is limited; it is recommended to replace part of animal fats with vegetable ones. Seafood is healthy, as well as vegetables and fruits containing a large amount of fiber.

The fight against physical inactivity is no less important. For daily cardio training, you must complete a course of special exercises, spend enough time in the fresh air.

Blood pressure control. It is necessary to strictly follow the recommendations for drug and non-drug treatment of arterial hypertension. It is most effective to create a pressure diary with a record of morning and evening readings. Such a simple method will not only help to carry out daily self-monitoring, but will also give the most complete picture of the disease to your doctor.

P .S. Remember, do not self-medicate, as not knowing the complications of drugs can lead to adverse consequences.

In our center, we will help not only to carry out the full scope of all the necessary examinations, but also to find the most effective and safest way to treat cardiovascular diseases.

Coronary artery disease (CHD)- organic and functional myocardial damage caused by a lack or cessation of blood supply to the heart muscle (ischemia). IHD can manifest itself as acute (myocardial infarction, cardiac arrest) and chronic (angina pectoris, postinfarction cardiosclerosis, heart failure) conditions. The clinical signs of ischemic heart disease are determined by the specific form of the disease. IHD is the most common cause of sudden death in the world, including among people of working age.

ICD-10

I20-I25

General information

Ischemic heart disease is a major problem in modern cardiology and medicine in general. In Russia, about 700 thousand deaths are annually recorded, caused by various forms of coronary artery disease, in the world mortality from coronary artery disease is about 70%. Ischemic heart disease mostly affects men of active age (55 to 64 years old), leading to disability or sudden death. The group of ischemic heart disease includes acutely developing and chronically proceeding states of myocardial ischemia, accompanied by its subsequent changes: dystrophy, necrosis, sclerosis. These conditions are considered, among other things, as independent nosological units.

Causes

The overwhelming majority (97-98%) of clinical cases of coronary artery disease is caused by atherosclerosis of the coronary arteries of varying severity: from a slight narrowing of the lumen by an atherosclerotic plaque to complete vascular occlusion. With 75% coronary stenosis, heart muscle cells respond to a lack of oxygen, and patients develop exertional angina.

Other causes of coronary artery disease are thromboembolism or spasm of the coronary arteries, usually developing against the background of an already existing atherosclerotic lesion. Cardiospasm aggravates the obstruction of the coronary vessels and causes manifestations of coronary heart disease.

The factors contributing to the onset of ischemic heart disease include:

• hyperlipidemia

Promotes 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 heart disease are hyperlipidemias of types IIa, IIb, III, IV, as well as a decrease in the content of alpha-lipoproteins.

Arterial hypertension increases the likelihood of developing coronary artery disease by 2-6 times. In patients with systolic blood pressure = 180 mm Hg. Art. and higher ischemic heart disease occurs up to 8 times more often than in hypotensive patients and people with normal blood pressure.

• smoking

According to various sources, smoking cigarettes increases the incidence of coronary artery disease by 1.5-6 times. Mortality from coronary heart disease among 35-64-year-old men who smoke 20-30 cigarettes daily is 2 times higher than among nonsmokers of the same age group.

• physical inactivity and obesity

Physically inactive people are at risk of developing coronary heart disease 3 times more than people leading an active lifestyle. When hypodynamia is combined with overweight, this risk increases significantly.

• impaired carbohydrate tolerance

• angina pectoris (stress):

1. stable (with the definition of functional class I, II, III or IV);
2. unstable: new-onset, progressive, early postoperative or postinfarction angina pectoris;

• spontaneous angina (syn. special, variant, vasospastic, Prinzmetal's angina)

• large focal (transmural, Q-infarction);
• small focal (not Q-infarction);

6. Violations of cardiac conduction and rhythm(form).

7. Heart failure(form and stages).

In cardiology, there is the concept of "acute coronary syndrome", which combines various forms of coronary heart disease: unstable angina pectoris, myocardial infarction (with Q-wave and without Q-wave). Sometimes this group also includes sudden coronary death caused by coronary artery disease.

CHD symptoms

Clinical manifestations of ischemic heart disease are determined by the specific form of the disease (see myocardial infarction, angina pectoris). In general, coronary heart disease has an undulating course: periods of stable normal health alternate with episodes of exacerbation of ischemia. About 1/3 of patients, especially those with painless myocardial ischemia, do not feel the presence of coronary artery disease at all. The progression of coronary heart disease can develop slowly over decades; in this case, the forms of the disease, and therefore the symptoms, can change.

Common manifestations of coronary artery disease include chest pain associated with physical exertion or stress, pain in the back, arm, lower jaw; shortness of breath, increased heart rate, or a feeling of interruption; weakness, nausea, dizziness, blurred consciousness and fainting, excessive sweating. Often, IHD is detected already 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.

The listed 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.

Precursors of primary cardiac arrest in ischemic heart disease can be paroxysmal discomfort behind the sternum, fear of death, psychoemotional lability. In case of sudden coronary death, the patient loses consciousness, breathing stops, there is no pulse in the main arteries (femoral, carotid), heart sounds are not heard, the pupils dilate, the skin becomes pale grayish. Cases of primary cardiac arrest account for up to 60% of lethal outcomes of ischemic heart disease, mainly at the prehospital stage.

Complications

Hemodynamic disorders in the heart muscle and its ischemic damage cause numerous morpho-functional changes that determine the forms and prognosis of coronary artery disease. The following decompensation mechanisms are the result of myocardial ischemia:

• insufficient energy metabolism of myocardial cells - cardiomyocytes;
• "Stunned" and "dormant" (or hibernating) myocardium - forms of impaired contractility of the left ventricle in patients with coronary artery disease, which are transient;
• the development of diffuse atherosclerotic and focal postinfarction cardiosclerosis - a decrease in the number of functioning cardiomyocytes and the development of connective tissue in their place;
• violation of the systolic and diastolic functions of the myocardium;
• disorder of the functions of excitability, conduction, automatism and contractility of the myocardium.

The listed morpho-functional changes in the myocardium in IHD lead to the development of a persistent decrease in coronary circulation, i.e., heart failure.

Diagnostics

Diagnosis of ischemic heart disease is carried out by cardiologists in a cardiological hospital or dispensary using specific instrumental techniques. When a patient is interviewed, complaints and the presence of symptoms characteristic of coronary heart disease are determined. On examination, the presence of edema, cyanosis of the skin, heart murmurs, rhythm disturbances is determined.

Laboratory diagnostic tests involve the study of specific enzymes that increase in unstable angina pectoris and heart attack (creatine phosphokinase (during the first 4-8 hours), troponin-I (for 7-10 days), troponin-T (for 10-14 days), aminotransferase , lactate dehydrogenase, myoglobin (on the first day)). These intracellular protein enzymes are released into the blood during the destruction of cardiomyocytes (resorption-necrotic syndrome). A study of the level of total cholesterol, lipoproteins of low (atherogenic) and high (antiatherogenic) density, triglycerides, blood sugar, ALT and AST (nonspecific markers of cytolysis) is also carried out.

The most important method for diagnosing cardiological diseases, including coronary heart disease, is ECG - registration of the electrical activity of the heart, which allows detecting violations of the normal operation of the myocardium. EchoCG - a method of ultrasound of the heart allows you to visualize the size of the heart, the state of the cavities and valves, to assess myocardial contractility, and acoustic noise. In some cases, with ischemic heart disease, stress echocardiography is performed - ultrasound diagnostics using dosed physical activity, recording myocardial ischemia.

Functional exercise tests are widely used in the diagnosis of coronary heart disease. They are used to detect the early stages of coronary artery disease, when violations cannot yet be determined at rest. As stress tests, walking, climbing stairs, loads on simulators (exercise bike, treadmill), accompanied by ECG fixation of heart performance indicators, are used. The limited use of functional tests in a number of cases is caused by the impossibility of performing the required load by patients.

CHD treatment

The tactics of treating various clinical forms of coronary heart disease has its own characteristics. Nevertheless, it is possible to outline the main directions used for the treatment of coronary artery disease:

• non-drug therapy;
• drug therapy;
• surgical revascularization of the myocardium (coronary artery bypass grafting);
• the use of endovascular techniques (coronary angioplasty).

Non-drug therapy includes measures to correct lifestyle and nutrition. With various manifestations of ischemic heart disease, a restriction of the mode of activity is shown, since during physical activity there is an increase in myocardial demand for blood supply and oxygen. Dissatisfaction with this need of the heart muscle actually causes manifestations of ischemic heart disease. Therefore, in any form of coronary heart disease, the patient's activity regimen is limited, followed by its gradual expansion during rehabilitation.

The diet for ischemic heart disease involves limiting the intake of water and salt with food to reduce the load on the heart muscle. In order to slow the progression of atherosclerosis and combat obesity, a low-fat diet is also prescribed. The following product groups are limited and, if possible, excluded: animal fats (butter, lard, fatty meat), smoked and fried foods, rapidly absorbed carbohydrates (baked goods, chocolate, cakes, sweets). To maintain a healthy weight, a balance must be struck between energy consumption and energy expenditure. If it is necessary to reduce weight, the deficit between consumed and consumed energy reserves should be at least 300 kC per day, taking into account that a person spends about 2000-2500 kC per day during normal physical activity.

Drug therapy for ischemic heart disease is prescribed according to the formula "A-B-C": antiplatelet agents, β-blockers and cholesterol-lowering drugs. In the absence of contraindications, it is possible to prescribe nitrates, diuretics, antiarrhythmic drugs, etc. The lack of effect of the ongoing drug therapy for coronary heart disease and the threat of myocardial infarction are an indication for consulting a cardiac surgeon to resolve the issue of surgical treatment.

Surgical revascularization of the myocardium (coronary artery bypass grafting - CABG) is resorted to in order to restore blood supply to the ischemic area (revascularization) with resistance to pharmacological therapy (for example, with stable angina pectoris III and IV FC). The essence of the CABG method is the imposition of an autovenous anastomosis between the aorta and the affected heart artery below the site of its narrowing or occlusion. Thus, a bypass vascular bed is created that delivers blood to the site of myocardial ischemia. CABG operations can be performed using artificial circulation or on a beating heart. Percutaneous transluminal coronary angioplasty (PTCA), a balloon "expansion" of a stenotic vessel, followed by implantation of a stent frame that maintains a vessel lumen sufficient for blood flow, is a minimally invasive surgical technique for IHD.

Forecast and prevention

Determination of the prognosis for coronary artery disease depends on the relationship of various factors. So the combination of coronary heart disease and arterial hypertension, severe lipid metabolism disorders and diabetes mellitus adversely affects the prognosis. Treatment can only slow down the steady progression of coronary artery disease, but not stop its development.

The most effective prevention of coronary artery disease is to reduce the adverse effects of threat factors: elimination of alcohol and tobacco smoking, psychoemotional overload, maintaining optimal body weight, exercise, blood pressure control, healthy eating.

Catad_tema Heart failure - articles

Catad_tema ischemic heart disease (coronary heart disease) - articles

Cardiac ischemia. Modern reality according to the world register CLARIFY

Cardiology (Kardiologia), 8, 2013 S.A. Shalnova, R.G. Oganov, F.G. Stag, J. Ford on behalf of the CLARIFY Registry Members
FSBI State Research Center for Preventive Medicine of the Ministry of Health of the Russian Federation, 101990 Moscow, Petroverigsky per., 10; INSERM U698, Paris, France; University Paris Diderot, Paris, France; AP-HP, Hopital Bichat, Paris, France; University of Glasgow, Glasgow, UK

The features of the clinical picture and treatment of coronary heart disease in Russia are presented in comparison with other countries according to the results of the world register CLARIFY. Russian participants in the CLARIFY registry from 43 regions included 2,249 patients in the registry in accordance with the inclusion and exclusion criteria. It turned out that Russian patients are younger and are characterized by a higher prevalence of risk factors and comorbidity. Thus, they have a significantly more frequent history of cardiovascular diseases, they smoke more often (20.9% versus 11.8%; p<0,0001), чаше имеют нарушения липидного обмена (77,8% против 74,6%; р<0,0001) и артериальную гипертонию (79,6% против 70,3%; р<0,0001), у них выше частота сердечных сокращений (р<0,0001). Следует отметить, что при достоверно более высокой частоте развития инфаркта миокарда по данным анамнеза (78,3% против 58,4%; р<0,0001), у них в 2,5 раза реже проводятся процедуры чрескожного коронарного вмешательства. Особенно существенные различия получены при сравнении частоты болевого синдрома у больных со стабильной стенокардией и хронической сердечной недостаточностью, которые выше у российских больных в 4,0 и 7,8 раза соответственно, при том, что частота назначения лекарственных препаратов в нашей стране практически такая же, как и в других странах. Полученные результаты должны заставить задуматься российских врачей, как преодолеть "особенности национального лечения больных со стабильной формой ишемической болезни сердца".

Keywords: ischemic heart disease, register, risk factors, diagnosis, treatment.

Coronary Artery Disease in Russia: Today "s Reality Evidenced by the International CLARIFY Registry

S.A. Shalnova, R.G. Oganov, PH. G. Steg, I. FORD on behalf of participants of the CLARIFY registre
Research Center for Preventive Medicine, Petroverigsky per. 10, 101990 Moscow on behalf of participants of the, Russia

This paper presents the specific features of clinical manifestation and treatment of coronary heart disease (CHD) in the Russian Federation and compares them to the data from other countries participating in the international CLARIFY (Prospective observational LongitudinAl Registry oF patients with stable coronary arterY disease) Registry ... In accordance with the exclusion and inclusion criteria, 2249 patients from 43 Russian regions were included in the Registry. Russian patients were younger and had a higher prevalence of risk factors and comorbidities, compared to patients from other countries. In particular, the former more often had cardiovascular disease in family history, smoked (20.9% vs. 11.8%; p<0.0001), and had dyslipidemia (77.8% vs. 74.6%; p<0.0001) or hypertension (79.6% vs. 70.3%; p<0.0001).They also had a higher heart rate (p<0.0001). While the incidence of myocardial infarction, based on medical history, was significantly higher than in patients from other countries (78.3% vs. 58.4%; p<0.0001), percutaneous coronary intervention (PCI) was performed 2.5 times less often. Particularly striking differences were observed for the prevalence of stable angina and heart failure, which was, respectively, 4.0 and 7.8 times higher in Russian patients, despite the fact that the prescription frequency was similar in the Russian Federation and other countries. These findings should focus Russian doctors" attention on the potential ways to solve the problem of "national features" in the treatment of stable CHD.

Key words: coronary heart disease; Registry; risk factors; diagnostics; treatment.

Cardiovascular disease (CVD) remains the leading cause of death worldwide. At the same time, in the last decades of the last century in economically developed countries, there was a clear decrease in mortality from diseases of the circulatory system (CVD), including coronary heart disease (IHD). In our country, a similar dynamics of mortality from CSD has been observed only in the most recent years. The highest mortality rate from CSD in Russia was registered in 2003. In subsequent years, there was a gradual decrease in mortality from CSD, which in 2011 reached 18.8%. However, the dynamics of the decrease in mortality from coronary artery disease was much more modest and amounted to only 10%. It should be noted that, despite the trend, mortality from coronary artery disease in our country is 3 times higher than in the United States.

The prevalence of ischemic heart disease in our country is 13.5%, in the United States - almost 2 times lower - 7%. It is important to note that an increase in the epidemic of CSD in the world is expected. According to P. Heidenreich et al. (2011), the prevalence of ischemic heart disease by 2030 will increase by 9.3%, and direct medical costs will increase by 198% compared with those in 2010. Thus, IHD remains the main cause of mortality and disability in the population. It is obvious that the current situation necessitates the improvement of treatment and prophylactic measures in this disease.

One of the tools for assessing the quality of diagnosis and treatment of patients with a particular pathology is a register. It is an organized system for collecting information about patients with a specific disease.

The register is carried out for a long time, which makes it possible to assess not only the quality of care for patients with a certain disease, but also long-term results.

In 2010, the global registry of patients with stable coronary artery disease (The prospeCtive observational LongitudinAl Registry oF patients with stable coronary arterY disease - CLARIFY) was launched, which should help improve our knowledge about patients with stable coronary artery disease in various geographic regions of the world. The purpose of the register is to provide a deeper understanding of the processes occurring in real clinical practice in patients with coronary artery disease; identifying the differences between actual treatment and recommendations and, ultimately, improving the treatment of such patients.

This paper presents a comparative analysis of the characteristics of IHD patients in Russia and other countries.

Material and methods

In this work, descriptive statistics methods were used: mean and standard deviations (Χ ± s), medians (Me) and interquartile deviations (QQ) for continuous variables and percentages for categorized variables. The differences were assessed as statistically significant at the 5% level. The study was conducted in accordance with the principles of the Declaration of Helsinki and approved by the National Ethics Committee. All patients signed informed consent. The CLARIFY register is registered in the ISRCTN registry of clinical trials No. ISRCTN43070564.

Results and discussion
The CLARIFY registry is an international, prospective, outpatient-based registry that contains the full range of characteristics of patients with coronary artery disease. Baseline information included demographic data; medical history, risk factors and behavioral habits, results of physical examination; clinical symptoms; laboratory data (fasting glucose, glycated hemoglobin, cholesterol, triglycerides, serum creatinine and hemoglobin) and information on drug therapy (if it was regularly used in the patient, at least 7 days before inclusion in the register). A detailed study protocol was presented earlier. The planned follow-up period is 5 years.

The register included patients from 45 countries of the world. In Russia, 243 doctors from 43 regions of the country take part in the register. Each of the doctors sequentially included at least 10 patients with coronary artery disease according to the criteria.

Inclusion criteria.

Documented myocardial infarction - MI (more than 3 months ago).

Coronary stenosis is more than 50% according to coronary angiography.

Chest pain in the presence of ischemic changes on the electrocardiogram during exercise test, stress echocardiography or myocardial imaging.

Coronary artery bypass grafting or percutaneous coronary intervention - PCI (more than 3 months ago).

Exclusion criteria:

Hospitalization with CVD within the last 3 months (including revascularization).

Scheduled revascularization.

The presence of an obstacle to the patient's participation in the registry (5 years of follow-up); limited cooperation, disability, severe non-CVD, cancer, drug addiction, severe heart failure, valvular disease).

The data obtained was collected centrally using a standard international information and registration form, translated into Russian, and sent electronically to the general control center, where the data was checked for completeness and correctness of filling. The collected data were analyzed at the Robertson independent statistical center for biostatistics at the University of Glasgow (UK).

In total, 2249 patients are included in the register in Russia. A comparative analysis of the primary results of the register showed that there are more women in the sample of Russian patients than in other countries (26.9% versus 22.2%; р<0,0001) (табл. 1).

Table 1. Socio-demographic and behavioral characteristics of patients included in the study

Indicator	Russia (n = 2249)	Other countries (n = 31,034)	P
Average age, years	59,2	64,5	<0,0001
Men, %	73,1	77,8	<0,0001
Higher secondary education	44,4	26,0	<0,0001
Current smoking,%	20,9	11,8	<0,0001
Alcohol, portions * / week			<0,0001
0	43,8	48,7
>0 <20	5,0	3,1
20-40	50,8	47,9
>40	0,4	0,3
Physical activity
No	4,6	17,1	<0,0001
easy almost every day	67,1	50,2
medium intensity almost every day	20,7	16,5
> 20 min intensive 1-2 times a week	7,6	16,2
Body mass index, kg / m 2 **	28,6 (26-31,6)	27,2 (24,1-30,1)	<0,0001
Waist circumference, cm **	97 (90-105)	96,5 (88-105)	0,08

Note.* - one serving = 12 g of pure alcohol; ** - data are presented as Me (Q 1 -Q 3).

Russian patients are significantly younger (5.3 years); this means that the onset of ischemic heart disease in them occurs much earlier than in patients in other countries. It should be noted that Russian patients are more educated: among them, people with higher education are observed almost 2 times more often than in other countries.

As expected, Russian patients smoke almost 2 times more often, which reflects the population level of smoking in Russia, which is one of the most smoking countries in Europe. Patients with coronary artery disease in Russia consume alcohol a little more often, but the number of people who consume alcohol excessively does not differ significantly from that in other countries (5.4% versus 3.4%). Russian patients are more physically active, although they do less intense physical activity.

There were no differences between the groups of patients in the size of the waist circumference (97 cm - in Russia versus 96.5 cm in other countries), while the average body mass index (height / body weight 2) was significantly higher in our patients: 28.7 (26 : 31.6) versus 27.2 (24.7: 30.1; p & lt0.0001).

It is important to note that our patients have a more burdened personal and family history (Table 2).

Table 2. Anamnestic data of patients with coronary artery disease in Russia and in other countries,%

Indicator	Russia (n = 2249)	Other countries (n = 31,034)	P
Family history of early CVD	37,5	27,8	<0,0001
AG	79,6	70,3	<0,0001
SD	16,7	30,1	<0,0001
Ischemic heart disease	0,2	1,3	<0,0001
Dyslipidemia	77,8	74,6	0,0001
History of myocardial infarction	78,3	58,4	<0,0001
History of PCI	28,6	60,8	<0,0001
History of CABG	22,9	23,5	<0,0001
Peripheral artery disease	13,9	9,5	<0,0001
History of stroke	4,3	4,0	0,4189
History of TIA	2,4	3,1	0,08
Hospitalization for CHF	7,8	4,4	<0,0001
Bronchial asthma, COPD	5,6	7,5	0,0011

Note. Ischemic heart disease - ischemic heart disease; CVD - cardiovascular disease; AH - arterial hypertension; DM - diabetes mellitus; PCI - percutaneous coronary intervention; CABG - coronary artery bypass grafting; TIA - transient ischemic attack; CHF - chronic heart failure; COPD is a chronic obstructive pulmonary disease.

An exception is diabetes mellitus (DM), which is significantly more common in other countries (30.1% versus 16.7%; p<0,0001). Так, в исследовании EUROASPIRE III (2009) СД выявлялся у 25% больных ИБС , тогда как по данным российских исследований, включавших аналогичных больных, частота развития СД варьирует от 14,1% в исследовании ПРИМА до 22% в исследовании ОСКАР . Обращает внимание, что при более частом ИМ в анамнезе ангиопластика (чрескожное коронарное вмешательство - ЧКВ) таким больным в нашей стране выполнялась почти в 2 раза реже, чем в других странах (28,6% против 60,8%), хотя аортокоронарное шунтирование (АКШ) проводилось так же часто, как и зарубежным больным. Действительно, ангиопластика существенно реже используется в практике российского кардиолога, чем хотелось бы. Так, Ю.А. Васюк и соавт. (2008), анализируя результаты исследования ПРИМА, показали, что в аналогичной когорте больных ИБС ЧКВ проводилось лишь у 5,6% , а по данным М.Г. Бубновой и соавт. (2009), изучавших подобных больных, этот показатель составил 6,9% . В то же время, по данным С.А. Бойцова и соавт. (2010), в 2009 г. доля больных с острым коронарным синдромом, подвергнутых ЧКВ, составила 19,8%, а результаты регистра РЕКОРД продемонстрировали, что в стационарах, где имеется возможность инвазивного вмешательства, эта доля в 2010 г. составляла 35% . Такое разнообразие данных объясняется критериями отбора больных для исследования. Однако, безусловно, российские больные ИБС существенно реже подвергаются ЧКВ.

At the same time, despite the higher blood pressure (BP), the incidence of cerebral stroke and transient ischemic attacks in the history of our patients practically does not differ from that in other countries. These results are very similar to those obtained in other studies. So, in the PREMIERA study (2007) in patients with arterial hypertension (AH) and IHD, a history of stroke was detected in 7.6% of men and 7.1% of women, and in the ORIGINAL study (2011), which included patients with AH, stroke or A history of TIAs was detected in 5%. Attention is drawn to the more frequent than in other countries, hospitalization for the progression of chronic heart failure (CHF).

Russia is characterized by a significant prevalence of hypertension, therefore, higher blood pressure in our patients is not surprising (Table 3).

Table 3. Results of clinical and laboratory studies in patients with coronary artery disease in Russia and other countries

Indicator	Russia (n = 2249)	Other countries (n = 31,034)	P
Systolic blood pressure, mm Hg	133,7	130,8	<0,0001
Diastolic blood pressure, mm Hg	82,7	76,8	<0,0001
Pulse for a. radialis, beats / min	70,0	68,2	<0,0001
Pulse on the electrocardiogram, beats / min	69,0	67,0	<0,0001
Pacemaker,%	0.8	2.5	<,0001
Atrial fibrillation / flutter,%	3,0	3,5
Complete left bundle branch block,%	3,2	5,0
Left ventricular ejection fraction,%	56,7	56,0	<0,0001
Glycated hemoglobin,%	6,8	6,8	0,95
Creatinine, mmol / l	0,090	0,088	<0,0001
Hemoglobin, mmol / l	8,8	8,7	<0,0001
Glucose, mmol / l	5,2	5,7	<0,0001
Total cholesterol, mmol / l	5,0	4,2	<0,0001
HDL cholesterol, mmol / l	1,2	1,1	0,01
LDL cholesterol, mmol / l	3,0	2,3	0,08
Triglycerides, mmol / l	1,6	1,4	0,4169

Note. Ischemic heart disease - ischemic heart disease; BP - blood pressure; CS - cholesterol; HDL - high density lipoproteins; LDL - low density lipoprotein.

The heart rate (HR) is also on average 2 beats / min higher than that of residents of other countries. Both of these indicators are independent risk factors for death from CVD in the Russian population.

Interestingly, the left ventricular ejection fraction in Russian patients is significantly higher than in similar patients in other countries. However, the clinical significance of this difference is not so obvious, it can be explained by the large sample size.

Analysis of biochemical parameters showed that, compared with residents of other countries, domestic patients are characterized by a higher level of total cholesterol - 5.0 mmol / L versus 4.2 mmol / L (р<0,0001) и более низкий уровень глюкозы в крови - 5,2 ммоль/л и 5,7 ммоль/л (р<0,0001). Последний соответствует более низкой частоте развития СД в нашей стране.

The most significant differences were found when comparing the symptoms of stable angina pectoris and CHF. Thus, in the Russian population of IHD patients included in the register, 75.4% have symptoms of stable angina pectoris, while in other countries - only 18.1% (p<0,0001) (рис. 1, А).

Rice. one. Symptoms of angina pectoris and CHF in patients with coronary artery disease in Russia and other countries according to the register.
A - angina pectoris; B - chronic heart failure (CHF); here and in fig. 2: Ischemic heart disease - ischemic heart disease.

Moreover, patients with stable angina pectoris II and III functional class (FC) according to the classification of the Canadian Association of Cardiology in our sample were found 4.7 and 6.9 times, respectively, than in other countries. Such differences are first shown in the large multicenter study ATP (Angina Treatment Patterns) -Survey. It was carried out in the early 2000s in 9 European countries, including 18 centers in Russia, where it was shown that among Russian patients with stable angina pectoris there were approximately 2 times more patients than those with FC III angina pectoris. Unfortunately, this gap has only widened over the years. Analysis of domestic studies showed that the number of patients with angina pectoris II and III FC is currently 60 and 31%, respectively, according to the PRIMA study, and 65.8 and 25.2% - according to the PERSPECTIVE study. Similar data are given by Yu.A. Karpov and A.D. Deev in the research ALTERNATIVE. It should be regretted that the high prevalence of angina pectoris symptoms is characteristic of Russian clinical practice.

In Russian patients with coronary artery disease, CHF is complicated in 77.5% of cases, that is, 7.7 times more often than in other countries (Fig. 1, B). In domestic patients, CHF II FC is recorded more than 8 times more often according to the classification of the New York Heart Association (NYHA) and 2 times more often - III FC. Such a high frequency of CHF in Russian clinical practice is confirmed in other Russian studies, where CHF is present in about 76% of patients with IHD. This raises doubts about the correctness of the diagnosis of CHF, although the figures given are repeated in almost all domestic clinical studies.

Such a significant prevalence of symptoms of angina pectoris and CHF raises questions about whether our patients are being treated correctly. However, an analysis of the therapy prescribed in Russian practice showed that the frequency of administration of acetylsalicylic acid, β-blockers, angiotensin-converting enzyme inhibitors significantly exceeds that in other countries (Fig. 2).

Rice. 2. Medical treatment of patients with coronary artery disease in Russia and other countries according to the register.
ASA - acetylsalicylic acid; BB - β-blockers; AK - calcium antagonists not dhp AK - nondihydropyridine calcium antagonists; LST - lipid-lowering therapy; CI - diuretics.

Lipid-lowering drugs (88% versus 93%) and other antianginal agents (31% versus 62%) are prescribed somewhat less frequently.

The obvious conclusion suggests itself that our doctors are sufficiently qualified and familiar with Russian and international recommendations for the treatment of coronary artery disease and prescribe the correct treatment, however, the symptoms persist, possibly due to the fact that either patients poorly adhere to the prescribed treatment regimen, or the doses of drugs prescribed by doctors are far from optimal. Even in the ATP study, insufficient treatment efficacy was noted in Russian patients compared with European patients. Thus, the main feature of the clinical practice of ischemic heart disease in our country is the extremely high frequency of symptoms of angina pectoris and CHF with an adequate frequency of prescribing modern drugs. An exception is the insufficient use of PCI.

What are the possibilities for improving therapeutic measures in patients with coronary artery disease? The first is a steady increase in adherence to treatment. The work should be carried out constantly, the doctor should explain to the patient the need to follow medical recommendations. The second is the correct dosage regimen of drugs. In addition, it may be necessary to more carefully evaluate the symptoms of angina pectoris and CHF.

The most important possibility is to decrease the heart rate in patients with stable coronary artery disease. So, analyzing the data of the register CLARIFY, P. Steg et al. concluded that despite the high frequency of use of β-blockers, the resting heart rate of less than 70 beats / min was in 41.1% of patients with coronary artery disease, and this, as shown earlier, is associated with an overall worse state of health: in such patients, symptoms are more often recorded angina pectoris and ischemia. Obviously, there are prospects for a further decrease in heart rate in many patients with coronary artery disease. A large study is currently underway that will provide evidence as to whether this will lead to an improvement in symptoms and prognosis in these patients.

List of participants in the CLARIFY register.
Mordvinova N.I., Rudakova D.M., Zherebtsova A.G., Fedoskin V.N., Guryanova N.B., Lopatin Yu.M. (Volgograd); Bolotova N.I., Knyazeva V.V., Spitsina T.Yu., Sytilina N.N., Atamanchuk N.M., Giorgadze M.L. (Voronezh); Zarechnova S.V., Kutuzova S.A., Sharapova Yu.A., Freidlina M.S. (Yekaterinburg); Sinyukova O.L., Rostik S.M., Evtukhova L.G., Sukhanova L.V., Makhieva T.N., Ezhov A.V. (Izhevsk); Tereshko S.V., Kolesnikov V.F., Kochurov E.P., Marchenko B.I., Nurgalieva S.Yu., Galyavich A.S. (Kazan); Galeeva Z.M., Andreicheva E.N., Zakirova V.B., Baleeva L.V., Minsafina A.R., Skibitsky V.V. (Krasnodar); Borodina N.P., Arkhipova Yu.V., Krechunova T.N., Shcherbak M.F., Merhi A.V., Nikulina S.Yu. (Krasnoyarsk); Aksyutina N.V., Ratovskaya O.V., Suglobova E.A., Kozhelenko Yu.A., Potapova E.N., Ginzburg M.L. (Moscow region); Poluyanova G.E., Belousova N.P., Braginskaya L.M., Atueva Kh.S., Tsaryabina L.V., Kurekhyan A.S., Sanina N.P. Khishova N.N., Dubinina E.B., Demina O.V., Mochkina P.M., Bukanina E.I., Martsevich S.Yu. Tolpygina S.N., Polyanskaya Yu.N., Malysheva A.M., Kholiya T.G., Serazhim A.A., Voronina V.P., Lukina Yu.V., Dubinskaya R.E., Dmitrieva N A.A., Baichorov I.Kh., Kuzyakina M.V., Khartova N.V., Bokuchava N.V., Smirnova E.V., Esenokova A.K., Pavlova Yu.Yu. Smirnova O.L., Astrakhantseva P.V., Bykovskaya S.A., Charikova O.F., Zhabina L.I., Berdnik K.V., Karaseva T.M., Oleinikova N.V., Jha O .O., Grigoryan S.A., Yakovenko E.I., Ivashchenko T.N., Kiseleva I.V. (Moscow); Shokina T.V., Novikova M.V., Nikitin Yu.P. Khodanov A.I., Popova L.V., Latyntseva L.D., Kilaberia O.Kh., Makarenkova K.V., Mezentseva N.G. (Novosibirsk); Nosova N.P., Gerasimova T.P., Boykova L.G., Sharapova N.Ya., Kulikova Yu.G., Korennova O.Yu. (Omsk); Pasechnaya N.A., Bulakhova E.Yu., Kurochkina S.D., Bratishko I.A., Likhobabina O.G., Koziolova N.A. (Permian); Panova E.E., Voronina N.V., Bizyaeva N.N., Gusev O.L., Nevolina N.G., Chesnikova A.I. (Rostov-on-Don); Arsentyeva T.V., Budanova O.V., London E.M., Melnikova E.G., Khripun A.V., Kuzmin V.P. Polyaeva L.V., Osadchuk E.A., Krasnoslobodskaya O.V., Yakimova N.N., Lugin A.P., Duplyakov D.V. (Samara); Sosnova Yu.G., Andronova S.I., Kositsyna G.V., Shanina I.Yu., Kostomarova S.V., Bondarenko B.B .; Mingaleva S.V., Zatsarina E.P., Kozlov D.N., Davydova N.A., Larina O.V., Boboshina N.S.; Mingaleva S.V., Zatsarina E.P., Kozlov D.N., Davydova N.A., Larina O.V., Boboshina N.S. (Saint Petersburg); Malgina M.P., Omelchenko M.Yu., Gorlova I.A., Orlova O.V., Vasilyeva T.A., Eidelman S.E., Salakhova A.R., Katanskaya L.A., Dryagina E V.V., Sokolov I.M. (Saratov); Kuzmicheva M.D., Nikolaeva L.Yu., Varezhnikova O.V., Dmitrieva T.S., Mikhailova E.A., Feoktistova I.V. (Tolyatti); Yanina Yu.A., Kapustina L.A., Vazhdaeva Z.I., Golovina G.A., Fedorova N.I., Karamova I.M. (Ufa); Nikolaeva I.E., Fillipova O.A., Gareeva L.N., Tuktarova F.S., Khmelevskikh N.A., Shaposhnik I.I. (Chelyabinsk); Karnot V.I., Golub M.V., Surovtseva I.V., Kulygina V.E., Shelomova N.N., Eregin S.Ya. (Yaroslavl); Kruglova I.V., Pokrovskaya I.V., Khludeeva E.A. (Vladivostok); Rodina O.G., Polkina L.N., Biryukova N.B., Filippova E.A., Kotova E.V., Cherkashina A.L. (Irkutsk); Ignatieva T.G., Alekseeva T.P., Gruznykh L.V., Mozerova E.M., Moksyuta E.V., Petrichko T.A. (Khabarovsk); Kosachek E.M., Strumilenko N.G., Baranova O.V., Voronova T.A., Bayakhchan L.S., Ogarkov M.Yu. (Novokuznetsk); Milyashenko S.V., Elgina E.V., Shamsutdinova O.Yu., Shapovalova E.V., Popova N.I., Raikh O.I., Shalaev S.V. (Tyumen); Karnaukhova N.Sh., Rotenberger V.R., Isaeva L.I., Lebishak G.P., Ryzhkova V.A., Barbarash O.L. (Kemerovo); Pecherina T.B., Shafranskaya K.S., Zykov M.V., Belenkova Yu.A., Bochkareva Yu.V. (Penza); Kosareva L.A., Grechishkina O.A., Nikishina S.Yu., Ilyukhina A.A., Gureeva O.V., Gomova T.A. (Tver); Soin I.An., Erofeev S.N., Lebedev S.V., Kudryavtsev L.N., Gamzatov E.A., Tarlovskaya E.I. (Kirov); Maksimchuk N.S., Grekhova L.V., Kolevatova L.A., Kazakovtseva M.V., Yakushin SS. (Ryazan); Kolesova O.N., Zharikova L.V., Kukaleva V.I., Starostina N.N., Grushetskaya I.S., Goltyapin D.B. (Stavropol); Kazachkova V.Yu., Pashentseva I.E., Shimonenko S.E., Martyushov S.I., Sirazov I.M., Chernozemova A.V., Golubeva O.B., Motylev I.M. (Nizhny Novgorod).

LITERATURE
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3. Roger V.L., Go A.S., Lloyd-Jones D.M. et al. Heart disease and stroke statistics 2012 update: a report from the American Heart Association. Circulation 2012; 124: e2-e220.
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5. Heidenreich P.A., Trogdon J.G., Khavjou O.A. et al. Forecasting the Future of Cardiovascular Disease in the United States A Policy Statement From the American Heart Association. Circulation 2011; 123: 933-944.
6. Steg P.G. Heart rate management in coronary artery disease: the CLARIFY registry. Eur Heart J 2009; 11: D13-D18.
7. Shalnova S.A., Deev A.D., Oganov R.G. Smoking prevalence in Russia. Results of a survey of a national representative sample of the population. Prof sick and strengthened health 1998; 3: 9-12.
8. Kotseva K, Wood D., De Backer G. et al., EUROASPIRE Study Group. EUROASPIRE III: a survey on the lifestyle, risk factors and use of cardioprotective drug therapies in coronary patients from 22 European countries. Eur J Cardiovasc Prev Rehabil 2009; 16: 121 - 137.
9.Vasyuk Yu.A., Shalnova S.A., Shkolnik E.L., Kulikov K.G. PRIMA study: modified-release trimetazidine in the treatment of patients with stable angina pectoris who have had myocardial infarction. Epidemiological and clinical stages. Cardiology 2008; 12: 10-13.
10. Shalnova S.A., Deev A.D. Characterization of high-risk patients. Results of the epidemiological part of the OSCAR scientific and educational program. Cardiovask ter & prof 2006; 6: 58-63.
11. Bubnova M.G., Aronov D.M., Oganov R.G. et al. Clinical characteristics and general approaches to the treatment of patients with stable angina pectoris in real practice. Russian research PERSPECTIVE (part I). Cardiovask ter and prof 2010; 6: 47-56.
12. Boytsov S.A., Krivonos O.V., Oshchepkova E.V. and others. Evaluation of the effectiveness of the implementation of measures aimed at reducing mortality from vascular diseases in the regions included in the program in 2008, according to the monitoring data of the Ministry of Health and Social Development of Russia and the ACS Register for the period from 01.01.2009 to 31.12.2012. cardioweb.ru/files/any/articles/articles_3.pdf:
13. Erlikh A.D., Gratsianskiy N.A. on behalf of the participants of the RECORD register. Acute coronary syndrome without ST-segment elevations in the practice of Russian hospitals: comparative data from the RECORD-2 and RECORD registers. Cardiology 2012; 10: 9-16.
14. Shalnova S.A., Deev A.D., Karpov Yu.A. Arterial hypertension and coronary heart disease in the real practice of a cardiologist. Cardiovask ter and prof 2006; 1: 73-80.
15. Karpov Yu.A., Nedogoda S.V., Kislyak O.A., Deev A.D. on behalf of doctors - participants of the ORIGINAL program Main results of the ORIGINAL program. Cardiology 2011; 3: 38-43.
16. Oganov R.G., Shalnova S.A., Deev A.D. and others. Arterial hypertension, mortality from cardiovascular diseases and the contribution to life expectancy of the population. Prof ill and strengthened health 2001; 3: 8-11.
17. Deev A.D., Oganov R.G., Konstantinov V.V. and others. Pulse rate and mortality from cardiovascular diseases in Russian men and women. Results of an epidemiological study. Cardiology 2005; 10: 45-50.
18. Oganov R.G., Lepakhin V.K., Fitilev S.B. and other Features of diagnosis and treatment of stable angina pectoris in the Russian Federation (international study ATP - Angina Treatment Pattern). Cardiology 2003; 5: 9-15.
19. Eastaugh J.L., Calvert M.J., Freemantle N. Highlighting the need for better patient care in stable angina: results of the international Angina Treatment Patterns (ATP) Survey in 7074 patients. Family Practice 2005; 22: 43-50.
20. Karpov Yu.A., Deev A.D. ALTERNATIVE program - study of antianginal activity and tolerance of coraxan (ivabradine) and assessment of the quality of life of patients with stable angina pectoris: results of the epidemiological stage. Cardiology 2008; 5: 30-35.
21. Steg P. G., Ferrari R., Ford I. et al. Heart Rate and Use of Beta-Blockers in Stable Outpatients with Coronary Artery Disease. PLoS ONE 2012; 7: e36284. doi: 10.1371 / journal.pone.0036284
22. Ferrari R. A step further with ivabradine: SIGNIfY (Study assessInG the morbidity-mortality beNefits of the If inhibitor ivabradine in patients with coronarY artery disease). Eur Heart J 2009; 11: D19-D27.

Despite the advances made in recent years in the treatment of diseases of the circulatory system(BSK), they still remain the main cause of death for the population of Russia. From table. 1 shows that an increase in their share in 2006 occurred against the background of a decrease in the mortality rate of the population in general and caused by BSC in particular. It should be noted that this is the maximum specific weight for the period 1991–2006.

Table 1

Mortality from heart and vascular diseases (per 100 thousand population)

Indicator	2004 r.	2005 year	2006 year
Mortality: for all reasons
from diseases of the circulatory system
Share of BSC in all mortality,%
Including from coronary heart disease (CHD)
The share of ischemic heart disease in all mortality,%
The share of ischemic heart disease in mortality from BSC,%
Including from acute myocardial infarction (AMI), including repeated
The share of AMI in all mortality,%
The share of AMI in mortality from BSC,%

A similar situation has developed with coronary heart disease: the proportion of this pathology in all deaths, including due to CSD, slightly increased, and the mortality rate varied significantly in certain territories and federal districts. Table 2 shows the general and standardized death rates from coronary heart disease in comparison with the proportion of the population over working age in the respective districts.

Changes in these two types of indicators allow us to draw several conclusions and assumptions. First, the aging of the population is evident in all federal districts - an increase in the proportion of men aged 60 and over and women aged 55 and over.

table 2

Mortality rates of the population from ischemic heart disease (number of deaths per 100 thousand inhabitants)

Federal District (FO)	Indicators		Share of people over working age,%
	are common	standardized *
	2005/2006 g.	2005/2006 g.	2005/2006 g.
Central
Northwestern
Privolzhsky
Ural
Siberian
Far Eastern
Average in the RF

* Indicators calculated on the basis of the same age structure of the population of all territories.

Secondly, against the background of such dynamics, there was a decrease in the general and standardized mortality rates from coronary heart disease in all federal districts, with the exception of a slight increase in the overall indicator in the Southern FD. Third, the standardized indicators were slightly higher than the general indicators in the Ural, Siberian and Far Eastern FDs, where the proportion of the population of disabled age was below 18.5%. The difference was most significant in the last of the listed districts with the lowest proportion of older people.

On the example of territories with an even lower proportion of this contingent (13–14% and below), the informativeness of standardized indicators is especially evident in comparison with the general ones for an objective assessment of the importance of coronary heart disease as a cause of death of the population in a certain region. as a rule, the overall mortality rate in such territories is significantly lower than the average for Russia. However, when analyzing the standardized indicators that level the differences in the age structure of the population of the territories, the mortality rate turns out to be 1.5-4 times higher, in some cases significantly exceeding the national average (for example, in the Tyumen region, Khanty-Mansiysk, Nenets, Taimyr, Chukotka AO, etc.) or approaching it (in the Republic of Sakha, Kamchatka, Magadan regions).

The most unfavorable in terms of mortality from coronary heart disease (1.5 times and higher than the national average) in the last two years are Belgorod, Orel, Smolensk, Pskov regions, in which residents of retirement age accounted for 22.8–24.9%. the correlation coefficient between the general mortality rates in the country's territories and the share of the older population in them was 0.82. However, it cannot be ruled out that the principle of the formation of a diagnosis in the event of a lethal outcome affects the determination of the place of a particular pathology among the causes of death.

Proportion of deaths from acute myocardial infarction(AMI) among all deaths due to ischemic heart disease averaged 10.6% in terms of general indicators and 10.4% in terms of standardized ones, having slightly increased compared to 2006. It was the highest in the Far Eastern Federal District (19.7%) and the lowest - in the central federal district (9.2%). It should be noted that the Pearson correlation coefficient for this pathology between the two groups of indicators was less than 0.3. This result is a consequence of the low specific weight of AMI as a cause of death, which, possibly, to some extent may be due to the fact that when registering a death case in this contingent, they prefer to indicate coronary heart disease without specifying its form. Probably, this approach is considered appropriate when making a diagnosis, especially in elderly people, in those who died outside the hospital, who did not undergo a pathological and anatomical examination.

In recent years, there has been a slight decrease in the role of ischemic heart disease in the formation of the entire class of diseases of the circulatory system (Table 3).

Table 3

Diseases of the circulatory system and coronary heart disease (per 100 thousand adults)

As can be seen from the above data, the proportion of coronary heart disease in all cases of BSC has been gradually decreasing over several years, although in 2006 the increase in the incidence rate relative to 2004 averaged about 16.6%, compared to 2005 - more than 7.2%. The primary incidence of ischemic heart disease in the same period increased by 17.5 and 8.6%, respectively. It can be assumed that the increase in the prevalence of coronary heart disease is due to a constant increase in the number of older people, as well as an increasingly pronounced trend in the development of this disease in Russia at an earlier age, especially in men.

The dynamics of the incidence of ischemic heart disease in the federal districts in 2004-2006. reflected in table. 4.

As follows from the data presented, in 2006 compared to 2005 in all federal districts, an increase in the primary incidence of coronary artery disease was registered, somewhat varying in intensity. In the central FD, it was 4.0%, in the North-West - 3.3, in the South - 10.6, in the Volga - 11.7, in the Ural - 10.1, in the Siberian - 13.9,

Table 4

Primary incidence of ischemic heart disease (per 100 thousand adults)

Federal district	In total, cases of coronary artery disease were diagnosed for the first time			Including AMI			Recurrent AMI
	2004 r.	2005 year	2006 year	2004 r.	2005 year	2006 year	2004 r.	2005 year	2006 year
Central
Northwestern
Privolzhsky
Ural
Siberian
Far Eastern
Total in RF

In the Far East - 2.7%. In some areas, the growth of primary morbidity was slightly higher: by 23–32% (in the republics of Adygea, Dagestan, Kalmykia, Tatarstan). only in the Kemerovo region there was a twofold increase in the indicator (the number of newly registered cases increased from 8770 in 2005 to 17249 in 2006). this requires an urgent study of the current situation: it is necessary to find out what caused the growth - a targeted improvement in diagnostics or an actual increase in IHD cases? The share of people over working age in this territory has grown in comparison with 2005 from 19.6% to 19.8%. The excess of the average level of primary IHD morbidity in the country by 1.8–2.5 times remained in the Belgorod, Ivanovo and Novgorod regions, the Ingush and Chechen republics, and the Republic of Tatarstan.

The overall incidence of coronary artery disease in the adult population increased by an average of 3.6% compared to 2005, the most in the Siberian FD (7.9%), the least - in the central (1.0%). The indicators increased by 15-18% in the Belgorod and Tambov regions, the Karachay-Cherkess Republic and the Republic of Bashkortostan, and by 30% - in the Kemerovo region. A significant excess of the average level of CHD prevalence took place in the Novgorod (2.6 times) and Belgorod (84.3%) regions, in St. Petersburg (2.2 times) and Moscow (63.6%), in Altai Territory (by 66.7%).

the frequency of acute myocardial infarction (AMI) in 2006 decreased relative to 2005 by 1.3%, most of all in the Southern and Central Federal Districts (by 3.9 and 3.5%, respectively). In some territories, the increase in AMI cases was more significant: by 42.8% in the Leningrad Region, by 28.5% in the Nenets Autonomous District, by 23.1% in the Republic of Kalmykia, and by more than 12% in the Tver Region and the Altai Republic. The maximum excess of the average incidence of AMI in the country was noted in Kostroma (2.1 times), slightly less (1.8-1.5 times) - in Ivanovo, Tver and Yaroslavl regions, the Republic of Mordovia, more than 1.4 times - in the Leningrad, Kemerovo and Perm regions.

Cases of recurrent AMI in 2006 were registered in the country less often in comparison with 2005 by 2.9%. A decrease in the indicator was noted in six federal districts, more significant - in the Southern FD, an increase - only in the Siberian (by 0.9%). At the same time, in a number of regions there was a significant increase in the frequency of this pathology: by 92.5% - in Kabardino-Balkaria, by 35-50% - in the Pskov and Murmansk regions, Kalmykia, Karachay-Cherkessia and North Ossetia - Alania, by 20– 25% - in the Yaroslavl and Novosibirsk regions, the republics of Khakassia and Bashkortostan.

An excess of the average incidence rate of repeated AMI by 2 times or more was noted in the Yaroslavl, Astrakhan, Penza, Omsk and Chelyabinsk regions, Stavropol Territory, the republics of Kalmykia and Komi, 1.5-1.9 times - in Kostroma, Tver, Arkhangelsk, Murmansk , Volgograd, Kirov, Samara, Kemerovo regions, Mordovia, the Udmurt Republic and the Khabarovsk Territory.

In the period from 2003 to 2006, there was a slight change in the ratio of various forms of coronary artery disease. Table 5 shows the proportion of AMI in the first time registered and the general incidence of ischemic heart disease.

Table 5

The ratio of some forms of coronary heart disease,%

Thus, there is a slight decrease in the proportion of AMI, which is due, on the one hand, to a decrease in its frequency, and, on the other hand, to an increase in the number of all registered and new cases of IHD. The proportion of angina pectoris slightly increased, while its incidence over the period under review increased by 27.4%, including by 11.6% relative to 2005. The prevalence of angina pectoris (general morbidity) increased by 5.6%.

The current situation could be due to various factors (the level of diagnosis, the proportion of survivors after the first AMI, the quality of dispensary observation of patients with coronary artery disease, etc.). It should be noted that the coverage rate of dispensary observation at the end of 2006 of all patients with ischemic heart disease registered in the country averaged 36.8%; at the same time, in the territories with the maximum incidence rate, it varied from 13.2% in the Belgorod region to 64.4% in the Altai Territory. In Moscow, it was 26.5%, in St. Petersburg - 16.8, in the Belgorod region - 15.9%. At the same time, in a number of territories, with a relatively low incidence rate, the proportion of patients registered with dispensaries exceeded 50% (for example, in the Kursk, Astrakhan, Omsk, Chelyabinsk regions).

The clinical examination of patients with angina pectoris was carried out more actively, which is determined by the clinical features of this form of ischemic heart disease - the manifestation of the possibility of developing myocardial infarction, the possibility of death. On average, in the country, the proportion of patients with angina pectoris under dispensary supervision was 45.1%. The minimum level (20-25%) was noted only in the Oryol, Orenburg and Kamchatka regions, St. Petersburg and the Chechen Republic, 26-30% of such patients - in the Belgorod region, the republics of Karelia, Bashkortostan, Khakassia. Over 70% of patients with angina pectoris were under dispensary supervision in Volgograd, Kirov, Kurgan, Magadan, Tyumen (including Khanty-Mansi Autonomous Okrug) regions, in the republics of Adygea, Ingushetia, North Ossetia, in Altai Territory and Chukotka Autonomous Okrug. However, more than half of the territories in 2006 had a clinical examination coverage rate of less than 50%. It is noted that in most regions there is no correlation between the level of general morbidity and the size of the contingent under dispensary supervision.

Improving the effectiveness of treatment of diseases of the heart and blood vessels largely depends on the observance of an integrated approach when providing assistance to this contingent of patients (cardiological and cardiac surgery). The prevalence of ischemic heart disease, its role as a cause of disability, a decrease in the quality of life of a significant part of the population determined the permanent improvement of methods for treating various forms of this pathology. Along with the success in the development and use of new drugs in the country, there is a constant intensification of the use of surgical and interventional methods of treatment.

The experience of the most developed countries with the maximum activity of carrying out these interventions allows predicting a further decrease in deaths and an increase in the life expectancy of patients with coronary artery disease. An increase in the effectiveness of such interventions against the background of an expansion of indications and a decrease in postoperative mortality contributes to their further introduction into healthcare practice in developed countries of Europe and the United States.

Diseases of the circulatory system in the structure of the causes of mortality in the majority of these countries in 2000-2002. were less than 42% (with 56.1% in Russia (according to standardized coefficients)), for example, in France - 26.9%, in Italy - 38.0, in the UK - 37.2, in the USA - 35.8% etc. In the table. 6 shows the indicators of the use of invasive interventions in the Russian Federation over several years in comparison with the average value of this indicator in Europe (2003).

Table 6

Invasive interventions for coronary artery disease (per 1 million population)

Indicator	2001 year	2002 year	2003 r.	2004 r.	2005 year	2006 year	Europe, 2003
Coronary artery bypass grafting (CABG)
CA stenting
CS: stenting

* transluminal angioplasty.

These data indicate, firstly, the constant expansion of the use of direct myocardial revascularization methods in the treatment of patients with coronary artery disease in Russia, and secondly, the significant lag of our healthcare in this area from the practice of European countries.

It seems that the main reasons for this situation are the disunity of medical services, lack of continuity in the management of patients, lack of interaction between specialized institutions and the primary health care service, significant underfunding of most municipal, regional, federal medical institutions.

Of no small importance is the lack of production of consumables in the country (balloons, stents, myocardial stabilizers, oxygenators, etc.), as well as modern diagnostic equipment and even high-quality surgical instruments. Import purchases significantly increase the cost of treatment (this concerns the technical support of all high-tech methods used to treat patients). It is likely that the successful implementation of national projects in the field of cardiovascular surgery, combined with the creation of conditions for the development of the domestic medical industry and a number of other organizational measures, will significantly change the existing situation.

Table 7 shows the summary data of accounting cards received by the Scientific Council on Cardiovascular Surgery of the Russian Academy of Medical Sciences and the Ministry of Health and Social Development of Russia in 2006.In addition, in some cases, data from the departments of X-ray endovascular methods were taken into account, which sent information to the Russian Scientific Society of Interventional Radiologists and Endovascular Surgeons (institutions, who participated in the provision of surgical care to patients with coronary artery disease, have different departmental subordination).

Table 7

Surgical treatment of ischemic heart disease

Type of intervention	Number of cases			Number of institutions
	2004 r.	2005 year	2006 year	2004 r.	2005 year	2006 year
KSh + valve surgery
CABG + operations on other vascular basins
CABG without artificial circulation
Including at ORKK *
Including at the URKK
CA stenting

* Acute coronary circulation disorder.

as follows from the above data, the volume of surgical treatment for coronary artery disease has increased compared to 2004 by 61%, compared to 2005 - by 34.3%. At the same time, the increase in the number of patients who underwent coronary artery bypass grafting was 47.6 and 24.4%, respectively. The average mortality rate in bypass surgery in 2006 was 3.15% (in 2005 - 3.2%). According to the Ministry of Health and Social Development of Russia, this figure was 3.1%, as in 2005.

The number of patients with simultaneous correction of the heart valve (s) defect increased in comparison with 2004 by 40.4%, since 2005 - by 35.2%. In this case, valve defects had a different etiology (rheumatism, infectious valvular endocarditis, myxomatosis, dysplastic process, myocardial ischemia, atherosclerosis, etc.). The proportion of cases of surgery for valvular pathology during CABG in 2006 was 6.9% (in 2005 - 6.3%). The average postoperative mortality rate was 8.9% (10.5% in 2005) with a wide range of values ​​- from 0 to 19%. Comparison of this indicator in individual clinics suggests that the determining factor should be considered the patient's condition, and in particular, the contractility of the myocardium, the degree of vascular damage, the completeness of revascularization, etc.

Valve replacement was still the main method of correcting concomitant heart valve disease in patients with coronary artery disease. Significantly less frequently, revascularization of the brain or extremities was performed simultaneously, and interventions were performed on the ascending aorta. The growth in the number of such transactions relative to 2005 is 47.6%. In almost 70% of cases, these were patients with pathology of the branches of the aortic arch. Mortality during such operations averaged about 8.4%.

The share of bypass surgeries performed in patients with acute coronary circulation disorder (ARCS) varied from 6.1% in 2004 to 6.6% in 2006. At the same time, their absolute number increased 1.6 times compared to 2004. , in comparison with 2005 - by 47.6%. Postoperative mortality in these cases averaged 6.3% (in 2005 - 8.6%). As follows from the data obtained, the number of institutions providing assistance to this contingent increased significantly in 2006, but in most of them the number of such patients was very small, and the proportion of interventions for ARCK in the entire volume of IHD surgery in these clinics was different. the number of bypass surgeries in the immediate period of AMI amounted to 22.5% of all operations for ARCC (mortality rate 14.1%) or 1.5% of all cases of CABG (in 2005 - 2.0%). Of course, performing myocardial revascularization in such cases is a measure aimed at preserving it.

Long-term experience of using vein and (or) artery grafts for coronary artery bypass grafting has shown the advantage of grafts in terms of ensuring the stability of their patency and maintaining the effectiveness of the intervention. In 2006, operations using only arterial grafts (in the overwhelming majority - the internal mammary artery) accounted for 9.9% of all cases. In 2005, autoarterial revascularization was performed in 6.4% of all CABG operations, in 2004 - in less than 6%. The use of only veins as shunts occurred in almost 6.3% of patients with CABG. In other cases, there was a combination of both types of grafts, which, to a certain extent, reduces the likelihood of reshunt operations. Currently, the number of repeated CABGs is insignificant - on average 1.2%, however, with an increase in the volume of coronary artery disease surgery, an increase in the number of reshunt operations can be expected.

Surgical treatment of coronary artery disease is performed mainly with the use of artificial circulation, but with an increase in the number of operated patients, the number of performed coronary bypass grafts on the beating heart also increased - by 33.9% compared to 2004, by 27.6% compared to 2005. their share in the total number of direct myocardial revascularization operations decreased from 16.9% in 2004 to 15.4% in 2006. Probably, this dynamics is determined by the increase in the number of patients with combined operations.

Postoperative mortality after CABG operations without extracorporeal perfusion was 1.4% (in 2005 - 0.9%). this is more than 2 times lower than when using extracorporeal perfusion. Such a situation is quite understandable, since the overwhelming majority of combined operations in patients with complications of myocardial infarction, lesions of the heart valves and (or) blood vessels were performed in conditions of artificial circulation.

Surgical treatment of AMI complications has intensified. Patients with this pathology represent the most severe contingent. The distribution of types of interventions in this group of patients is shown in Table. 8. Data were provided by 57 institutions (in 2005, such information was received from the 51st clinic).

Surgical treatment of complications of AMI

Table 8

* Ventricular septal defect.

Thus, in 2006, the number of operated patients with complications of acute myocardial infarction increased by 39.6% compared to 2005, while the proportion of postinfarction defects corrections without performing coronary bypass grafting decreased from 4.3 to 3.3% (in 2004 - 9.3%). Operated on patients with complications of AMI in 8.8% of cases of surgical treatment of coronary artery disease (7.5% in 2005, 8.8% in 2004). Postoperative mortality in such patients in 2006 decreased, according to the data presented, from 8.9% to 7.3%, but exceeded the average level in operations with direct myocardial revascularization by more than 2 times.

As the analysis of the performed operations shows, the most common and frequent complication of AMI is still left ventricular aneurysm (71.3% of cases in 2006, 82.5% in 2005). The use of various techniques for left ventricular reconstruction, providing its reverse remodeling and improving myocardial function, prevailed. The number of patients with correction of mitral insufficiency increased significantly - almost 2.8 times - and reconstructive techniques were used 1.9 times more often than valve replacement. In total, in 2006, 347 operations were performed for valve defects of ischemic origin.

With a general increase in the volume of surgical care for patients with coronary artery disease in certain areas, the nature of the changes was different. Table 9 shows the dynamics of the distribution of institutions where CABG was performed and operated patients in the federal districts of the Russian Federation.

Table 9

Coronary bypass surgery

Federal district	Number of clinics performing CABG			The number of patients operated on in the institutions of the federal district
	2004 r.	2005 year	2006 year	2004 r.	2005 year	2006 year
Central
Northwestern
Privolzhsky
Ural
Siberian
Far Eastern

As can be seen from the above figures, an increase in the volume of surgical care for coronary artery disease took place in institutions of all federal districts, with the exception of the Far East. The maximum increase in the number of CABs was noted in the Southern FD (40.7%), the minimum - in the Urals, in the rest it varied from 20.3 to 29.5%. However, it should be noted that the figures obtained are determined by the initial value - the smaller it is, the more significant the percentage increase seems to be.

In federal clinics of the Ministry of Health and Social Development of Russia or RAMS of the central FD, 56.9% of all direct myocardial revascularization operations were performed in this district, in clinics of other departments - 20.0%. In the Northwestern Federal District, this ratio was 36.6 and 12.7%, respectively. In the Siberian FD, more than 70% of such interventions were performed in clinics of federal subordination (the Ministry of Health and Social Development of Russia and the Russian Academy of Medical Sciences). In total, federal institutions in 2006 provided 39.8% of all coronary bypass grafts in the country. Since these clinics provide assistance to patients living in all territories of the country, it is difficult to assess the provision of the population of a particular region with this type of treatment based on the data presented.

The application of endovascular surgery methods is expanding at the fastest pace in the country, as well as throughout the world. offices, laboratories and departments in which diagnostic and therapeutic procedures are performed, function in conjunction with structures that conduct cardiological and (or) surgical treatment of patients with coronary artery disease. Increasingly, they are part of the emergency medical service.

According to the information received by the Scientific Council, in comparison with 2004, the number of cases of endovascular angioplasty increased by 73.6%, compared to 2005 - by 42.7%. The proportion of patients who received stents implanted increased over the year from 83.3% to 84.5%. the number of interventions carried out in connection with ORKK increased by 60.0%, their share increased from 26.3 to 29.5%. thus, the methods of endovascular surgery are used in ORKK much more often than surgical ones. At the same time, mortality after PSTA in 2006 averaged 0.52% (according to the annual report of the Ministry of Health and Social Development of Russia - 0.4%), in patients with ARC it reached 1.3% (in 2005 - 0.6 and 1.6%, respectively). The share of AMI among all cases of acute disorders of coronary circulation increased from 52.0 to 58.3% with a mortality rate of 2.0% (in 2005 - about 2.6%).

The number of endovascular surgical interventions and the number of institutions where these methods are used in the treatment of patients with coronary artery disease in the federal districts of the Russian Federation are given in Table. 10.

The rate of increase in the number of endovascular procedures compared to 2005 was different: more than 2 times growth in the Far Eastern Federal District, by 82.0% in the Ural Federal District, by 58.1% in the Siberian Federal District, and by more than 40% in the North-West Federal District. , Southern and Volga federal districts, by 23.7% - in the central FD. In all districts, with the exception of Privolzhsky, the proportion of interventions in patients during the period of ORKK increased, maximally in the South (from 10.4 to 25.2%) and the Far East (from 14.1 to 26.5%). However, the highest proportion of such cases in 2006 took place in the Siberian (34.9%), Ural (33.4%) and central (31.7%) FDs. the number of institutions where patients with coronary artery disease are treated using X-ray surgical methods increased by 13 (about 15%) in comparison with 2004.

If we focus on the corresponding indicators in the advanced European countries, the provision of the population with interventional and surgical methods for the treatment of coronary artery disease in the country by the beginning of 2007 amounted to about 15 and 22%, respectively. The situation is aggravated by the fact that the number of patients with this pathology is constantly increasing. this is due to the development of coronary heart disease at an ever younger age, as well as the aging of the country's population.

In 2006, in the institutions of the Ministry of Health and Social Development of Russia, hospital mortality among AMI patients averaged 15.47% (in 2004 - 14.8%, in 2005 - 15.36%). The maximum indicator remained in the North-Western Federal District (17.3%), the minimum was noted in the Volga Federal District (13.4%). The average mortality rate in institutions of the Ural (14.0%), Siberian (14.6%), Southern (15.8%), central (16.7%) and Far Eastern (16.9%) federal districts is slightly higher.

Table 10

Surgical treatment of patients with coronary artery disease

Federal district	Number of cases Tlap			Including at the URKK			Number of institutions
	2004 r.	2005 year	2006 year	2004 r.	2005 year	2006 year	2004 r.	2005 year	2006 year
Central
Northwestern
Privolzhsky
Ural
Siberian
Far Eastern

Comparison of these figures with postoperative mortality rates when performing coronary artery bypass grafting or endovascular angioplasty of coronary arteries indicates the need to revise the principles of the cardiological service, in particular, to expand the contingent and improve dispensary observation of patients with various forms of coronary heart disease, to make wider use of modern diagnostic methods. state of the coronary bed and myocardium. In addition to coronary angiography, methods of visualization and assessment of the coronary bed using intravascular ultrasound and the method of virtual histology, computed tomography (X-ray and magnetic resonance imaging) should be used. They make it possible to give a reliable non-invasive assessment of the vascular bed, including in critically ill patients, to shorten the examination time, to provide an opportunity to simulate patches in cardiac aneurysm surgery and to select stents for endovascular surgery.

It seems appropriate to prevent the development of AMI and its complications by timely determining the patient's indications for direct myocardial revascularization and directing him to surgical treatment with endovascular or surgical methods. The necessary conditions for this are the awareness of cardiologists, their contact with cardiac surgeons, cooperation between cardiac dispensaries and cardiac surgery centers. In recent years, there have been more departments (rooms) for endovascular methods, operating around the clock, providing emergency care to patients admitted to emergency cardiology (cardiology) departments.

The constant increase in the number of patients with complicated forms of ischemic heart disease, with the development of heart failure, has led to the formation of new approaches to their treatment. One of them is the use of hybrid technologies - a combination of two or three techniques simultaneously or in stages (transmyocardial laser revascularization using a high-energy laser, coronary artery bypass grafting, transluminal angioplasty and stenting of coronary arteries, resynchronization and cell therapy). It became possible to provide assistance to the most severe category of patients, prolonging their life and improving its quality. However, it is possible to count on a reduction in premature mortality and disability of the population caused by coronary artery disease only when proven methods of myocardial revascularization are widely introduced, the level of their provision will be increased to the average in Europe. World practice shows that by investing additional funds in health care, the state in a few years receives a tangible economic effect from reducing the morbidity and mortality of the population.