Clinical guidelines for ischemic heart disease angina pectoris. Ischemic heart disease (CHD)

The most important diagnostic method for complaints of chest pain is the history taking.
At the diagnostic stage, it is recommended to analyze complaints and take anamnesis in all patients with suspected coronary artery disease.

Comments. The most common complaint in angina pectoris, as the most common form of stable CAD, is chest pain.
It is recommended to ask the patient about the existence pain syndrome in the chest, nature, frequency of occurrence and circumstances of disappearance.
Recommendation strength level I (Evidence level C).
Comments. Signs of a typical (undoubted) exertional angina:
Pain in the sternum, possibly radiating to the left arm, back or lower jaw, less often to the epigastric region, lasting 2-5 minutes. Pain equivalents are shortness of breath, a feeling of "heaviness", "burning".
The above pain occurs during physical exertion or severe emotional stress.
The above pain quickly disappears after the cessation of physical activity or after taking nitroglycerin.
To confirm the diagnosis of typical (undoubted) angina pectoris, the patient must have all three of the above signs at the same time.
There are atypical variants of localization of pain and irradiation. The main symptom of angina pectoris is a clear dependence of the onset of symptoms on physical activity.
The equivalent of angina pectoris can be shortness of breath (up to suffocation), a feeling of "heat" in the sternum, attacks of arrhythmia during exercise.
The equivalent of physical activity can be a crisis increase blood pressure(BP) with an increase in the load on the myocardium, as well as a plentiful meal.
The diagnosis of atypical angina is made if the patient has any two of the three signs of typical angina listed above.
Signs of non-anginal (non-anginal) chest pain:
Pain is localized alternately to the right and left of the sternum.
The pains are local, "point" character.
After the onset of pain lasts more than 30 minutes (up to several hours or days), it can be constant, “shooting” or “suddenly piercing”.
Pain not associated with walking or otherwise physical activity, however, occur when tilting and turning the body, in the prone position, with a long stay of the body in an uncomfortable position, with deep breathing at the height of inhalation.
Pain does not change after taking nitroglycerin.
Pain is aggravated by palpation of the sternum and / or chest along the intercostal spaces.
A feature of the pain syndrome in the chest with vasospastic angina pectoris is that the pain attack, as a rule, is very strong, localized in a “typical” place - in the sternum. However, often such attacks occur at night and early in the morning, as well as when exposed to cold on open areas of the body.
A feature of the pain syndrome in the chest with microvascular angina pectoris is that anginal pain, in terms of quality and localization corresponding to angina pectoris, but arising some time after exercise, and poorly relieved by nitrates, may be a sign of microvascular angina pectoris.
If during the questioning the syndrome of angina pectoris is detected, it is recommended to determine its functional class, depending on the exercise to be tolerated.
Recommendation strength level I (Evidence level C).
Comments. There are 4 functional classes (FC) of angina according to the classification of the Canadian Society of Cardiology (Table 1).
Table 1. Functional classes of angina pectoris.

Functional class I	Functional class II	Functional class III	Functional class IV
"Latent" angina pectoris. Seizures occur only under extreme stress	Attacks of angina pectoris occur during normal exercise: brisk walking, uphill, stairs (1-2 flights), after a heavy meal, severe stress	Attacks of angina sharply limit physical activity: they occur with a slight load: walking at an average pace< 500 м, при подъеме по лестнице на 1-2 пролета. Изредка приступы возникают в покое	Inability to perform any, even minimal load due to the occurrence of angina pectoris. Seizures occur at rest. Frequent history of myocardial infarction, heart failure

During the collection of anamnesis, it is recommended to clarify the fact of smoking now or in the past.
Recommendation strength level I (Evidence level C).
During the history taking, it is recommended to ask about the cases of CVD from the patient's immediate family (father, mother, siblings).
Recommendation strength level I (Evidence level C).
During the history taking, it is recommended to ask the patient's next of kin (father, mother, siblings) about CVD deaths.
Recommendation strength level I (Evidence level C).
During the history taking, it is recommended to ask about previous cases of treatment medical care and the results of such appeals.
Recommendation strength level I (Evidence level C).
During the collection of anamnesis, it is recommended to clarify whether the patient has previously recorded electrocardiograms, the results of other instrumental studies and conclusions on these studies.
Recommendation strength level I (Evidence level C).
During the history taking, it is recommended to ask the patient about known comorbidities.
Recommendation strength level I (Evidence level C).
During the history taking, it is recommended to ask the patient about all currently taken medications. medicines.
Recommendation strength level I (Evidence level C).
During the history taking, it is recommended to ask the patient about all drugs that were previously discontinued due to intolerance or ineffectiveness. Strength of recommendation IIa (Level of evidence C).

2.2 Physical examination.

At the stage of diagnosis, all patients are recommended to conduct a physical examination.
Recommendation strength level I (Evidence level C).
Comments. Usually, the physical examination for uncomplicated stable CAD has little specificity. Sometimes a physical examination can reveal signs of RF: overweight and signs of diabetes mellitus (DM) (scratching, dry and sagging skin, decreased skin sensitivity). Signs of atherosclerosis of the heart valves, aorta, main and peripheral arteries are very important: noise over the projections of the heart, abdominal aorta, carotid, renal and femoral arteries, intermittent claudication, cold feet, weakening of arterial pulsation and muscle atrophy lower extremities. A significant risk factor for coronary artery disease, detected during physical examination, is arterial hypertension (AH). In addition, you should pay attention to the external symptoms of anemia. In patients with familial forms of hypercholesterolemia (HCS), examination may reveal xanthomas on the hands, elbows, buttocks, knees, and tendons, as well as xanthelasmas on the eyelids. The diagnostic value of physical examination increases when symptoms of coronary artery disease complications are present - primarily signs of heart failure: shortness of breath, wheezing in the lungs, cardiomegaly, cardiac arrhythmia, swelling of the jugular veins, hepatomegaly, swelling of the legs. The detection of signs of heart failure during physical examination usually suggests postinfarction cardiosclerosis and a very high risk of complications, and therefore dictates the need for urgent complex treatment, including with possible myocardial revascularization.
During a physical examination, it is recommended to conduct a general examination, examine the skin of the face, trunk and extremities.
Recommendation strength level I (Evidence level C).
During the physical examination, it is recommended to measure height (m) and weight (kg) and determine the body mass index.
Recommendation strength level I (Evidence level C).
Comments. The body mass index is calculated by the formula - "weight (kg) / height (m) 2".
During a physical examination, it is recommended to auscultate the heart and lungs, palpate the pulse on the radial arteries and the arteries of the dorsal surface of the feet, measure blood pressure according to Korotkov in the patient’s position lying, sitting and standing, calculate the heart rate and pulse rate, auscultate the projection points of the carotid arteries, abdominal aorta, iliac arteries, palpate the abdomen, parasternal points and intercostal spaces.
Recommendation strength level I (Evidence level C).

2.3 Laboratory diagnostics.

Few laboratory tests have independent predictive value in stable CAD. The most important parameter is the lipid profile of the blood. Other laboratory tests of blood and urine allow to identify concomitant diseases and syndromes (dysfunction thyroid gland, diabetes mellitus, heart failure, anemia, erythremia, thrombocytosis, thrombocytopenia), which worsen the prognosis of coronary artery disease and require consideration in the selection of drug therapy and, if possible, referral of the patient to surgical treatment.
All patients are advised to general analysis blood with measurement of levels of hemoglobin, erythrocytes and leukocytes.

When clinically warranted, screening for type 2 diabetes is recommended to begin with measurements of glycosylated hemoglobin and fasting blood glucose. If the results are inconclusive, an oral glucose tolerance test is additionally recommended.

All patients are advised to conduct a study of blood creatinine levels with an assessment of kidney function by creatinine clearance.
Recommendation strength level I (level of evidence B).
All patients are advised to undergo lipid spectrum fasting blood, including an assessment of the level of low-density lipoprotein cholesterol (LDL-C).

Comments. Dyslipoproteinemia - a violation of the ratio of the main classes of lipids in plasma - the leading risk factor for atherosclerosis. Low density and very low density lipoproteins are considered protatherogenic, while high density lipoproteins are an antiatherogenic factor. With a very high content of LDL-C in the blood, IHD develops even in young people. Low HDL cholesterol is an unfavorable prognostic factor. High level blood triglycerides are considered a significant predictor of CVR.
When clinically warranted, thyroid function screening is recommended to detect thyroid disorders.

In patients with suspected heart failure, it is recommended to study the level of the N-terminal fragment of the brain natriuretic peptide in the blood.
Strength of recommendation IIa (level of evidence C);
In case of clinical instability of the condition or if ACS is suspected, repeated measurement of blood troponin levels by a highly or ultra-highly sensitive method is recommended to rule out myocardial necrosis.
Recommendation strength level I (Level of Evidence A);
In patients complaining of symptoms of myopathy while taking statins, it is recommended to study the activity of blood creatine kinase.
Recommendation strength level I (level of evidence C);
In repeated studies in all patients with a diagnosis of stable coronary artery disease, it is recommended to conduct an annual monitoring of the lipid spectrum, creatinine and glucose metabolism.
Recommendation strength level I (Evidence level C).

2.4 Instrumental diagnostics.

Electrocardiographic study.
All patients with suspected coronary artery disease, when contacting a doctor, are advised to perform electrocardiography (ECG) at rest and decipher the electrocardiogram.
Recommendation strength level I (level of evidence C) ;
Resting ECG is recommended for all patients during or immediately after an episode of chest pain suggestive of unstable CAD.
If vasospastic angina is suspected, an ECG recording during an attack of chest pain is recommended.
Recommendation strength level I (Evidence level C);
Comments. In uncomplicated stable CAD outside exercise, specific ECG signs of myocardial ischemia are usually absent. The only specific sign of IHD on the resting ECG is large-focal cicatricial changes in the myocardium after myocardial infarction. Isolated changes in the T wave, as a rule, are not very specific and require comparison with the clinic of the disease and data from other studies. Registration of an ECG during a pain attack in the chest is of much greater importance. If there are no ECG changes during pain, the probability of coronary artery disease in such patients is low, although it is not completely excluded. The appearance of any ECG changes during a pain attack or immediately after it significantly increases the likelihood of coronary artery disease. Ischemic ECG changes in several leads at once are an unfavorable prognostic sign. In patients with initially altered ECG due to postinfarction cardiosclerosis, ECG dynamics during an attack of even typical angina may be absent, be of little specificity, or false (decrease in amplitude and reversion of initially negative T waves). It should be remembered that against the background of intraventricular blockades, ECG registration during a pain attack is also uninformative. In such cases, the doctor decides on the nature of the attack and the tactics of treatment according to the accompanying clinical symptoms.
echocardiographic study.
A resting transthoracic echocardiogram (EchoCG) is recommended in all patients with suspected stable CAD and with previously proven stable CAD.
Recommendation strength level I (level of evidence B).
Comments. The main purpose of echocardiography at rest is the differential diagnosis of angina pectoris with non-coronary chest pain in malformations. aortic valve, pericarditis, ascending aortic aneurysm, hypertrophic cardiomyopathy, prolapse mitral valve and other diseases. In addition, echocardiography is the main way to detect and stratify myocardial hypertrophy, local and general left ventricular dysfunction.
A resting transthoracic echocardiogram (EchoCG) is done to:
ruling out other causes of chest pain;
detection of local disorders of the mobility of the walls of the left ventricle of the heart;
measurement of the left ventricular ejection fraction (LVEF) and subsequent CV risk stratification;
assessment of diastolic function of the left ventricle.
Ultrasound examination of the carotid arteries.
Ultrasound examination of the carotid arteries in stable CAD is recommended to detect atherosclerosis of the carotid arteries as an additional risk factor for CVE.

Comments. The detection of multiple hemodynamically significant stenoses in the carotid arteries forces us to reclassify the risk of CVE as high, even with moderate clinical symptoms.
X-ray examination in stable coronary artery disease.
At the diagnostic stage, a chest x-ray is recommended in patients with atypical symptoms of CAD or to rule out lung disease.
Recommendation strength level I (Evidence level C).
At the diagnostic stage, at follow-up, a chest x-ray is recommended if HF is suspected.
Strength of recommendation IIa (Level of evidence C).
A comment. Chest x-ray is most informative in patients with postinfarction cardiosclerosis, heart disease, pericarditis, and other causes of concomitant HF, as well as in suspected aneurysms of the ascending aortic arch. In such patients, on radiographs, it is possible to assess an increase in the heart and aortic arch, the presence and severity of intrapulmonary hemodynamic disorders (venous stasis, pulmonary arterial hypertension). In atypical chest pain, an X-ray examination can be useful for identifying diseases of the musculoskeletal system during the differential diagnosis.
ECG monitoring.
ECG monitoring is recommended in patients with proven stable CAD and suspected concomitant arrhythmias.
Recommendation strength level I (Evidence level C).
ECG monitoring is recommended at the diagnostic stage in patients with suspected vasospastic angina.
Strength of recommendation IIa (Level of evidence C).
ECG monitoring is recommended at the diagnostic stage if it is impossible to perform stress tests due to concomitant diseases (diseases of the musculoskeletal system, intermittent claudication, a tendency to a pronounced increase in blood pressure during dynamic physical exertion, detraining, respiratory failure).
Strength of recommendation IIa (Level of evidence C).
A comment. The method allows to determine the frequency of occurrence and duration of painful and painless myocardial ischemia. Sensitivity of ECG monitoring in the diagnosis of coronary artery disease: 44-81%, specificity: 61-85%. This diagnostic method is less informative for detecting transient myocardial ischemia than exercise tests. Prognostically unfavorable findings during ECG monitoring: 1) long total duration of myocardial ischemia; 2) episodes of ventricular arrhythmias during myocardial ischemia; 3) myocardial ischemia with low heart rate (< 70 уд. /мин). Выявление суммарной продолжительности ишемии миокарда 60 мин в сутки служит веским основанием для направления пациента на коронароангиографию (КАГ) и последующую реваскуляризацию миокарда, поскольку говорит о тяжелом поражении КА .
Evaluation of data from the primary survey and pre-test probability of coronary artery disease.
It is recommended that when examining individuals without a previously established diagnosis of coronary artery disease, it is recommended to assess the pre-test probability (PTP) of this diagnosis based on data obtained during the collection of anamnesis, physical and laboratory research, ECG at rest, echocardiography and performed according to the indications of chest x-ray, ultrasound carotid arteries and ambulatory ECG monitoring.
Recommendation strength level I (Evidence level C).
Comments. After the initial studies, the doctor builds a plan for further examination and treatment of the patient, based on the primary data obtained and the PTT of the diagnosis of stable coronary artery disease (Table 2).
Table 2. Pretest probability of a stable diagnosis coronary disease heart depending on the nature of chest pain.

Age, years	Typical angina		Atypical angina		Non-coronary pain
	men	women	men	women	men	women
30-39	59%	28%	29%	10%	18%	5%
40-49	69%	37%	38%	14%	25%	8%
50-59	77%	47%	49%	20%	34%	12%
60-69	84%	58%	59%	28%	44%	17%
70-79	89%	68%	69%	37%	54%	24%
80	93%	76%	78%	47%	65%	32%

It is recommended that in patients with PTV diagnosed with coronary heart disease 65%, further studies to confirm the diagnosis should not be carried out, but proceed to the stratification of the risk of CVD and the appointment of treatment.
Recommendation strength level I (Evidence level C).
Recommended. Patients with PTV diagnosed with coronary artery disease< 15% направить на обследование для выявления функционального заболевание сердца или некардиальных причин clinical symptoms.
Recommendation strength level I (Evidence level C).
It is recommended that patients with intermediate PTT diagnosed with CAD (15-65%) be referred for additional non-invasive exercise and imaging tests. diagnostic tests.
Recommendation strength level I (Evidence level C).
ECG registration during exercise tests.
Stress ECG with exercise is recommended as an initial method for establishing the diagnosis of angina syndrome against the background of intermediate PTT detection of coronary artery disease (15-65%), not taking anti-ischemic drugs.
Recommendation strength level I (Level of evidence B).
Comments. An exercise stress ECG is not performed when the patient is unable to exercise or if the underlying changes in the ECG make evaluation impossible.
An exercise stress ECG is recommended in patients with established CAD and on treatment to assess its effect on symptoms and myocardial ischemia.
Strength of Recommendation IIa (Level of Evidence C) ;
Stress ECG with exercise is not recommended in patients receiving cardiac glycosides, as well as with ST segment depression on the ECG at rest of 0.1 mV.
Level of recommendation III (Level of evidence C).
A comment. Typically, the stress test is a bicycle ergometry or treadmill test. The sensitivity of stress ECG with exercise in the diagnosis of coronary artery disease is 40-50%, the specificity is 85-90%. The walking test (treadmill test) is more physiological and is more often used to verify the functional class of patients with coronary artery disease. Bicycle ergometry is more informative in detecting coronary artery disease in unclear cases, but at the same time it requires the patient to have at least basic cycling skills, it is more difficult to perform in elderly patients and with concomitant obesity. The prevalence of transesophageal atrial electrical stimulation in the daily diagnosis of coronary artery disease is lower, although this method is comparable in informational content to bicycle ergometry (VEM) and the treadmill test. The method is performed according to the same indications, but is the means of choice if the patient cannot perform other stress tests due to non-cardiac factors (diseases of the musculoskeletal system, intermittent claudication, a tendency to a pronounced increase in blood pressure during dynamic physical exertion, detraining, respiratory failure). .
Stress methods for visualization of myocardial perfusion.
Stress methods of myocardial perfusion imaging include:
Stress echocardiography with exercise.
Stress echocardiography with pharmacological loading (dobutamine or vasodilator).
Stress echocardiography with a vasodilator.
Perfusion myocardial scintigraphy with physical activity.
Stress echocardiography is one of the most popular and highly informative methods for non-invasive diagnosis of coronary artery disease. The method is based on visual detection of local LV dysfunction, as an equivalent of ischemia, during exercise or a pharmacological test. Stress EchoCG is superior to conventional exercise ECG in terms of diagnostic value, has greater sensitivity (80-85%) and specificity (84-86%) in the diagnosis of coronary artery disease. The method allows not only to verify ischemia conclusively, but also to preliminarily determine symptom-related coronary artery disease by the localization of transient LV dysfunction. With technical feasibility.
Stress echocardiography with exercise is indicated for all patients with proven coronary artery disease for verification, symptom-related coronary artery disease, as well as in doubtful results of a conventional exercise test during the initial diagnosis.
Strength of recommendation IIa (Level of evidence C).
If microvascular angina is suspected, stress echocardiography with exercise or dobutamine is recommended to verify local hypokinesis of the LV wall, which occurs simultaneously with angina and ECG changes.
Strength of recommendation IIa (Level of evidence C);
If microvascular angina is suspected, echocardiography with Doppler examination of the left coronary artery with measurement of diastolic coronary blood flow after intravenous administration of adenosine is recommended to study the coronary blood flow reserve.
Strength of recommendation IIb (Level of Evidence C).
A comment. Myocardial perfusion scintigraphy (single photon emission computed tomography and positron emission tomography) is a sensitive and highly specific imaging method with high prognostic value. The combination of scintigraphy with physical activity or pharmacological tests (dosed intravenous administration of dobutamine, dipyridamole) greatly increases the value of the results obtained. The method of positron emission tomography makes it possible to estimate the minute blood flow per unit mass of the myocardium and is especially informative in the diagnosis of microvascular angina pectoris.
Conducting a scintigraphic study of myocardial perfusion in combination with physical activity is recommended for stable CAD for verification, symptom-related coronary artery disease and for assessing the prognosis of the disease.
Strength of Recommendation IIa (Level of Evidence C);
A scintigraphic study of myocardial perfusion in combination with a pharmacological test (intravenous administration of dobutamine or dipyridamole) is recommended for stable coronary heart disease for verification, symptom-related coronary artery disease and for assessing the prognosis of the disease if the patient cannot perform standard physical activity (due to detraining, diseases of the musculoskeletal system). apparatus and/or lower extremities, etc.).

Positron emission tomography of myocardial perfusion is recommended in the diagnosis of microvascular angina.
Strength of Recommendation IIb (Level of Evidence C);
Stress imaging is recommended as the initial method for diagnosing stable CAD with a PTT of 66-85% or with an LVEF.< 50% у лиц без типичной стенокардии .
Strength of Recommendation I (Level of Evidence B);
Stress imaging is recommended as an initial diagnostic method if resting ECG features preclude its interpretation during exercise.
Recommendation strength level I (Level of evidence B).
Exercise-assisted imaging is recommended over pharmacological exercise.
Strength of Recommendation I (Level of Evidence C);
Stress imaging is recommended as the preferred method in individuals with symptoms of coronary artery disease who have undergone prior percutaneous coronary intervention (PCI) or coronary artery bypass surgery(KSH) .
Strength of recommendation IIa (Level of evidence B);
Stress imaging is recommended as the preferred method for assessing the functional significance of intermediate stenoses according to CAG.
Strength of Recommendation Level IIa (Level of Evidence B) ;
In patients with stable CAD with a pacemaker, stress echocardiography or single photon emission is recommended. computed tomography.

Stress imaging for CV risk stratification is recommended in patients with inconclusive exercise stress ECG results.

CV risk stratification using stress ECG or stress imaging is recommended in patients with stable CAD when there is a significant change in the frequency and severity of symptoms.
Recommendation level I (Level of evidence B).
With concomitant blockade of the left branch of the His bundle, stress echocardiography or single-photon emission computed tomography of the myocardium with a pharmacological load is recommended for stratification according to the risk of CVE.
Strength of recommendation IIa (Level of evidence B).
Invasive studies in stable coronary artery disease.
Invasive coronary angiography (CAG) is traditionally the "gold standard" in the diagnosis of coronary artery disease and in risk stratification of complications.
With proven coronary artery disease, coronary angiography is recommended for risk stratification of CV events in individuals with severe stable angina (FC III-IV) or with clinical signs high risk of CVD, especially when symptoms are difficult to treat.
Recommendation strength level I (Evidence level C).

Indications for conducting research methods are indicated in accordance with the classes: class I - studies are useful and effective; IIA - data on usefulness are inconsistent, but there is more evidence in favor of the effectiveness of the study; IIB - data on usefulness are inconsistent, but the benefits of the study are less obvious; III - research is useless.

The degree of evidence is characterized by three levels: level A - there are several randomized clinical trials or meta-analyses; level B - data obtained in a single randomized trial or in non-randomized trials; level C - recommendations are based on expert agreement.

• with stable angina or other symptoms associated with coronary artery disease, such as shortness of breath;
• with established coronary artery disease, currently asymptomatic due to treatment;
• patients in whom symptoms are noted for the first time, but it is established that the patient has a chronic stable disease (for example, from the anamnesis it was revealed that such symptoms have been present for several months).

Thus, stable coronary artery disease includes different phases of the disease, except for the situation when clinical manifestations are determined by thrombosis of the coronary artery (acute coronary syndrome).

With stable coronary artery disease symptoms during exercise or stress associated with stenosis of the trunk of the left coronary artery > 50% or stenosis of one or more large arteries> 70%. This edition of the Guidelines discusses diagnostic and prognostic algorithms not only for such stenoses, but also for microvascular dysfunction and coronary artery spasm.

Definitions and pathophysiology

Stable CAD is characterized by a mismatch between oxygen demand and delivery, leading to myocardial ischemia, which is usually provoked by physical or emotional stress, but sometimes occurs spontaneously.

Episodes of myocardial ischemia are associated with chest discomfort (angina pectoris). Stable coronary artery disease also includes an asymptomatic phase of the course of the disease, which may be interrupted by the development of an acute coronary syndrome.

Different clinical manifestations of stable CAD are associated with different mechanisms, including:

• obstruction of the epicardial arteries,
• local or diffuse spasm of the artery without stable stenosis or in the presence of an atherosclerotic plaque,
• microvascular dysfunction,
• left ventricular dysfunction associated with a previous myocardial infarction or with ischemic cardiomyopathy (myocardial hibernation).

These mechanisms can be combined in one patient.

Natural course and forecast

In a population of patients with stable coronary artery disease, individual prognosis may vary depending on clinical, functional, and anatomical characteristics.

It is necessary to identify patients with more severe forms of the disease, whose prognosis may be better with aggressive intervention, including revascularization. On the other hand, it is important to identify patients with mild forms of the disease and a good prognosis, in whom unnecessary invasive interventions and revascularization should be avoided.

Diagnosis

Diagnosis includes clinical evaluation, imaging studies, and imaging of the coronary arteries. Studies can be used to confirm the diagnosis in patients with suspected coronary artery disease, identify or exclude comorbid conditions, risk stratification, and evaluate the effectiveness of therapy.

Symptoms

When assessing chest pain, the Diamond A.G. classification is used. (1983), according to which typical, atypical angina and non-cardiac pain are distinguished. An objective examination of a patient with suspected angina pectoris reveals anemia, arterial hypertension, valvular lesions, hypertrophic obstructive cardiomyopathy, rhythm disturbances.

It is necessary to assess the body mass index, identify vascular pathology(pulse on peripheral arteries, murmur on carotid and femoral arteries), identification of comorbid conditions such as thyroid disease, kidney disease, diabetes mellitus.

Non-invasive research methods

The optimal use of non-invasive testing is based on an assessment of the pretest probability of CAD. Once the diagnosis is established, management depends on the severity of symptoms, risk, and patient preference. It is necessary to choose between drug therapy and revascularization, the choice of the method of revascularization.

The main studies in patients with suspected CAD include standard biochemical tests, ECG, 24-hour ECG monitoring (if symptoms are suspected of being related to paroxysmal arrhythmia), echocardiography, and, in some patients, chest x-ray. These tests can be done on an outpatient basis.

echocardiography provides information about the structure and function of the heart. In the presence of angina pectoris, it is necessary to exclude aortic and subaortic stenosis. Global contractility is a prognostic factor in patients with CAD. Echocardiography is especially important in patients with heart murmurs, myocardial infarction, and symptoms of heart failure.

Thus, transthoracic echocardiography is indicated for all patients for:

• exclusion of an alternative cause of angina pectoris;
• detection of violations of local contractility;
• ejection fraction (EF) measurements;
• assessment of left ventricular diastolic function (Class I, level of evidence B).

There is no indication for repeat studies in patients with uncomplicated coronary artery disease in the absence of changes in the clinical condition.

Ultrasound examination of the carotid arteries necessary to determine the thickness of the intima-media complex and / or atherosclerotic plaque in patients with suspected coronary artery disease (Class IIA, level of evidence C). Detection of changes is an indication for prophylactic therapy and increases the pretest probability of CAD.

Daily ECG monitoring rarely provides additional information compared to exercise ECG tests. The study is of value in patients with stable angina and suspected arrhythmias (Class I, level of evidence C) and in suspected vasospastic angina (Class IIA, level of evidence C).

X-ray examination indicated in patients with atypical symptoms and suspected lung disease (Class I, level of evidence C) and in suspected heart failure (Class IIA, level of evidence C).

A step-by-step approach to diagnosing CAD

Step 2 is the use of non-invasive methods for the diagnosis of coronary artery disease or non-obstructive atherosclerosis in patients with an average likelihood of coronary artery disease. When the diagnosis is established, optimal drug therapy and risk stratification of cardiovascular events are required.

Step 3 - non-invasive tests to select patients in whom invasive intervention and revascularization are more beneficial. Depending on the severity of symptoms, early coronary angiography (CAG) may be performed bypassing steps 2 and 3.

The pretest probability is estimated taking into account age, gender, and symptoms (table).

Principles for the use of non-invasive tests

The sensitivity and specificity of non-invasive imaging tests is 85%, hence 15% of the results are false positive or false negative. In this regard, testing of patients with low (less than 15%) and high (more than 85%) pretest probability of CAD is not recommended.

Stress ECG tests have low sensitivity(50%) and high specificity (85-90%), so tests are not recommended for diagnosis in a group with a high probability of coronary artery disease. In this group of patients, the goal of performing stress ECG tests is to assess the prognosis (risk stratification).

Patients with a low EF (less than 50%) and typical angina are treated with CAG without non-invasive tests, as they are at very high risk of cardiovascular events.

Patients with a very low probability of CAD (less than 15%) should rule out other causes of pain. With an average probability (15-85%), non-invasive testing is indicated. In patients with a high probability (more than 85%), testing is necessary for risk stratification, but in severe angina, it is advisable to perform CAG without non-invasive tests.

The very high negative predictive value of computed tomography (CT) makes it important for patients with lower mean risk (15-50%).

Stress ECG

A VEM or treadmill is shown at a pre-test probability of 15-65%. Diagnostic testing is performed when anti-ischemic drugs are discontinued. The sensitivity of the test is 45-50%, the specificity is 85-90%.

The study is not indicated for blockade of the left bundle branch block, WPW syndrome, the presence of a pacemaker due to the inability to interpret changes in the ST segment.

False positive results are seen with ECG changes associated with left ventricular hypertrophy, electrolyte disturbances, violations of intraventricular conduction, atrial fibrillation, taking digitalis. In women, the sensitivity and specificity of the tests is lower.

In some patients, testing is uninformative due to failure to achieve submaximal heart rate in the absence of symptoms of ischemia, with limitations associated with orthopedic and other problems. An alternative for these patients are imaging methods with a pharmacological load.

• for the diagnosis of coronary artery disease in patients with angina pectoris and an average likelihood of coronary artery disease (15-65%) who are not receiving anti-ischemic drugs, who can exercise and have no ECG changes that do not allow interpretation of ischemic changes (Class I, level of evidence B);
• to evaluate the effectiveness of treatment in patients receiving anti-ischemic therapy (Class IIA, level C).

Stress echocardiography and myocardial perfusion scintigraphy

Stress echocardiography is performed using exercise (VEM or treadmill) or pharmacological preparations. Exercise is more physiological, but pharmacological exercise is preferred when contractility is impaired at rest (dobutamine to assess viable myocardium) or in patients unable to exercise.

Indications for stress echocardiography:

• for the diagnosis of coronary artery disease in patients with a pretest probability of 66-85% or with EF<50% у больных без стенокардии (Класс I, уровень доказанности В);
• for the diagnosis of ischemia in patients with ECG changes at rest that do not allow interpretation of the ECG during exercise tests (Class I, level of evidence B);
• exercise stress testing with echocardiography is preferred over pharmacological testing (Class I, level of evidence C);
• in symptomatic patients who underwent percutaneous intervention (PCI) or coronary artery bypass grafting (CABG) (Class IIA, level of evidence B);
• to assess the functional significance of moderate stenoses detected in CAH (Class IIA, level of evidence B).

Perfusion scintigraphy (BREST) ​​with technetium (99mTc) reveals myocardial hypoperfusion during exercise compared to perfusion at rest. Provocation of ischemia by physical activity or medication with the use of dobutamine, adenosine is possible.

Studies with thallium (201T1) are associated with a higher radiation load and are currently used less frequently. The indications for perfusion scintigraphy are similar to those for stress echocardiography.

Positron emission tomography (PET) has advantages over BREST in terms of image quality, but is less accessible.

Non-Invasive Techniques for Evaluating Coronary Anatomy

CT can be performed without contrast injection (calcium deposition is determined in coronary arteries) or after intravenous administration contrast iodine preparation.

Calcium deposition is a consequence of coronary atherosclerosis, except in patients with renal insufficiency. When determining coronary calcium, the Agatston index is used. The amount of calcium correlates with the severity of atherosclerosis, but the correlation with the degree of stenosis is poor.

Coronary CT angiography with the introduction of a contrast agent allows you to assess the lumen of the vessels. The conditions are the patient's ability to hold his breath, the absence of obesity, sinus rhythm, heart rate less than 65 per minute, the absence of severe calcification (Agatston index< 400).

Specificity decreases with an increase in coronary calcium. Carrying out CT angiography is impractical when the Agatston index > 400. The diagnostic value of the method is available in patients with the lower limit of the average probability of coronary artery disease.

Coronary angiography

CAG is rarely needed for diagnosis in stable patients. The study is indicated if the patient cannot be subjected to stress imaging research methods, with an EF of less than 50% and typical angina pectoris, or in persons of special professions.

CAG is indicated after non-invasive risk stratification in the high-risk group to determine indications for revascularization. In patients with a high pretest probability and severe angina, early coronary angiography without previous non-invasive tests is indicated.

CAG should not be performed in patients with angina who refuse PCI or CABG or in whom revascularization will not improve functional status or quality of life.

Microvascular angina

Primary microvascular angina should be suspected in patients with typical angina positive results stress ECG tests in the absence of stenotic lesions of the epicardial coronary arteries.

Research required for the diagnosis of microvascular angina:

• stress echocardiography with exercise or dobutamine to detect local contractility disorders during an angina attack and ST segment changes (Class IIA, level of evidence C);
• transthoracic doppler echocardiography of the anterior descending artery with measurement of diastolic coronary blood flow after intravenous administration of adenosine and at rest for non-invasive evaluation of coronary reserve (Class IIB, level of evidence C);
• CAG with intracoronary administration of acetylcholine and adenosine in normal coronary arteries to assess coronary reserve and determine microvascular and epicardial vasospasm (Class IIB, level of evidence C).

Vasospastic angina

For diagnosis, it is necessary to register an ECG during an angina attack. CAG is indicated for evaluation of coronary arteries (Class I, level of evidence C). 24-hour ECG monitoring to detect ST segment elevation in the absence of an increase in heart rate (Class IIA, level of evidence C) and CAG with intracoronary administration of acetylcholine or ergonovine to identify coronary spasm (Class IIA, level of evidence C).

Ischemic heart disease is a common cardiovascular pathology resulting from impaired blood supply to the myocardium.

Ischemic heart disease is the most common in Russia among all cardiovascular diseases.

In 28% of cases, it is she who is the reason for the treatment of adults in medical institutions.

At the same time, only half of the patients with coronary artery disease know that they have this pathology and receive treatment, in all other cases, ischemia remains unrecognized, and its first manifestation is acute coronary syndrome or myocardial infarction.

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ICD-10 diagnoses

1. I20.1 Angina pectoris with documented spasm
2. I20.8 Other angina pectoris
3. I20.9 Angina pectoris, unspecified
4. I25 Chronic ischemic heart disease

Ischemic heart disease is a lesion of the heart muscle associated with impaired blood flow through the coronary arteries.

This violation, in turn, is organic (irreversible) and functional (transient).

In the first case, the main cause of IHD is stenosing atherosclerosis. Factors of functional damage to the coronary arteries are spasms, transient platelet aggregation, and intravascular thrombosis.

The concept of "ischemic heart disease" includes both acute transient (unstable) and chronic (stable) conditions.

Most often, the main causes of CAD are stable anatomical atherosclerotic and/or functional stenosis of the epicardial vessels and/or microvascular dysfunction.

The main risk factors for coronary heart disease:

1. High blood cholesterol.
2. Diabetes.
3. arterial hypertension.
4. Sedentary lifestyle.
5. Tobacco smoking.
6. Overweight, obesity.

✔ Distribution of patients with coronary artery disease according to the degree of risk based on non-invasive diagnostic methods, download the table in the Consilium System.

Download table

In addition, risk factors for CHD that cannot be influenced are:

• belonging to the male sex;
• age;
• burdened heredity.

In addition, there are social risk factors that increase the incidence of CHD among the population of developing countries:

• urbanization;
• industrialization;
• economic backwardness of the population.

Ischemia in humans develops when the need of the heart muscle for oxygen exceeds the ability to deliver it with blood through the coronary arteries.

The mechanisms for the development of coronary artery disease are:

• a decrease in coronary reserve (the ability to increase coronary blood flow with an increase in the metabolic needs of the myocardium);
• primary decrease in coronary blood flow.

The oxygen demand of the heart muscle is determined by three factors:

1. Tension of the walls of the left ventricle.
2. Myocardial contractility.

The higher the value of each of these indicators, the higher the myocardial oxygen demand.

The amount of coronary blood flow depends on:

• coronary artery resistance;
• heart rate;
• perfusion pressure (the so-called difference between diastolic pressure in the aorta and the same in the left ventricle).

angina pectoris

Angina pectoris is the most common form of cardiac ischemia. Its frequency increases with age in both men and women. Annual lethality from coronary artery disease is about 1.2-2.4%, and 0.6-1.4% of patients die from fatal cardiovascular complications every year, while the percentage of non-fatal myocardial infarctions is 0.6-2, 7 per year.

However, in subpopulations with various additional risk factors, these values ​​may be different.

Patients diagnosed with stable angina pectoris die from ischemia 2 times more often than patients without this diagnosis. There are currently no epidemiological data on microvascular and vasospastic angina.

Revascularization of the heart muscle in order to stop angina attacks, reduce its functional class and improve the quality of life is recommended for all patients with angina pectoris in the presence of coronary stenosis > 50 percent with documented myocardial ischemia or fractional blood flow reserve (FRF) ≤ 0.80 in combination with angina pectoris (and / or its equivalents), refractory to drug therapy.

It must be said that for coronary artery stenoses less than 90%, additional tests are needed to prove their hemodynamic significance (documented myocardial ischemia, including according to stress tests with myocardial imaging or determination of FFR).

Myocardial revascularization to improve the prognosis of the underlying pathology is indicated in all patients with a large area of ​​ischemia (>10% in the left ventricle), as well as in all patients with a single preserved artery with >50% stenosis.

Surgery on the coronary arteries improves the prognosis of patients with extensive ischemia.

A large zone of damage to the heart muscle can be judged by the presence of a hemodynamically important lesion of a large coronary artery:

• trunk of the left coronary artery;
• proximal anterior descending artery;
• two- or three-vessel lesions with a decrease in left ventricular function;
• the only surviving coronary vessel.

When choosing a method, factors such as:

1. Anatomical features of the lesion of the coronary arteries.
2. Associated diseases and possible risks.
3. Consent of the patient to a specific method of surgical treatment.

In the event that both AOS and PCI with stenting are possible, and the patient agrees to any type of intervention, the choice of technique is determined anatomical features coronary lesions.

Ischemic heart disease: treatment

The conservative treatment of stable cardiac ischemia is based on the elimination of risk factors that can be influenced, as well as complex drug treatment. The patient must be informed of all risks and of the treatment strategy.

When taking an anamnesis and examination, it is necessary to pay attention to comorbidities, especially when it comes to arterial hypertension, diabetes and hypercholesterolemia.

Eliminating risk factors is a complex and indefinitely long task. The most important role here is played by informing and educating the patient, since only a knowledgeable and trained patient will clearly follow medical advice and will be able to make important decisions in the future depending on the symptoms.

• discuss with the patient how drug treatment, and surgical intervention;
• specify the need and frequency of instrumental and laboratory tests;
• talk about the most common symptoms of unstable angina, AMI, emphasize the importance of promptly contacting specialists when they occur;
• give clear recommendations on maintaining a healthy lifestyle, emphasizing the importance of treating concomitant diseases.

Drug therapy aims to eliminate clinical manifestations IHD, as well as the prevention of complications from the heart and blood vessels. It is recommended that the patient be prescribed at least one drug to eliminate the symptoms of angina pectoris in combination with prophylactic drugs.

For citation: Soboleva G.N., Karpov Yu.A. Recommendations of the European Society of Cardiology for stable coronary artery disease 2013: microvascular angina // BC. 2013. No. 27. S. 1294

In September 2013, new guidelines for the diagnosis and treatment of stable coronary artery disease (CHD) were presented. Among the many changes in recommendations, angina pectoris with normal coronary arteries (CA), or microvascular angina pectoris, is receiving increased attention. The range of clinical and pathological correlations between the symptoms and the nature of changes in the coronary artery in angina pectoris is quite wide and varies from typical manifestations of angina pectoris due to stenosing coronary artery disease and transient myocardial ischemia to a pain syndrome atypical for angina pectoris with unchanged coronary arteries. This ranges from pain syndrome atypical for angina against the background of significant stenoses in the coronary artery, eventually acquiring the form of a diagnosis of "angina pectoris", to a typical clinic of the disease against the background of unchanged coronary arteries, which is proposed to be identified as "microvascular angina" (MVS) in the Recommendations of 2013 - for stable angina pectoris, or earlier - cardiac syndrome X (CSX).

The definition of "KSH" was first applied in 1973 by Dr. H.G. Kemp, who drew attention to the research of Canadian scientists R. Arbogast and M.G. Bou-rassa. The pain syndrome in this group of patients may differ in the following characteristics:
1) pain can cover a small part of the left half of the chest, last from several hours to several days and not be stopped by taking nitroglycerin;
2) pain may have typical characteristics of an anginal attack in terms of localization, duration, but at the same time occur at rest (atypical angina pectoris due to vasospasm);
3) manifestation of a pain syndrome with typical characteristics of an anginal attack is possible, but longer in time without a clear connection with physical activity and negative result stress tests, which corresponds clinical picture MVS.
Diagnosis and determination of treatment tactics in patients with MVS is a difficult task. In a significant proportion of patients (approximately 50% of women and 20% of men) in the presence of angina, coronary angiography (CAG) does not reveal atherosclerosis of the epicardial arteries, which indicates a dysfunction (coronary reserve) of microvessels. Data from the National Heart, Lung, and Blood Institute's Women's Ischemia Syndrome Evaluation (WISE) study demonstrated a 2.5% annual risk of adverse cardiovascular events in this group of patients, including death, myocardial infarction, stroke, and heart failure. The results of a 20-year follow-up of 17,435 patients in Denmark with normal coronary artery disease and non-obstructive diffuse coronary artery disease with angina pectoris showed a 52% and 85% increase in the risk of major cardiovascular events (cardiovascular death, hospitalization for MI, heart failure, stroke) and 29 and 52% increased risk of overall mortality, respectively, in these groups without significant differences by gender.
Despite the absence of a universal definition of MVS, the presence of a triad of signs corresponds to the main manifestations of the disease:
1) typical exercise-induced angina (in combination or in the absence of rest angina and dyspnea);
2) the presence of signs of myocardial ischemia according to ECG, Holter ECG monitoring, stress tests in the absence of other diseases of the cardiovascular system;
3) unchanged or slightly changed CA (stenosis<50%) . Наиболее чувствительным методом диагностики ишемии миокарда у этих больных является применение фармакологических тестов или ВЭМ-теста в сочетании с однофотонной эмиссионной компьютерной томографией миокарда при введении 99mTc-МИБИ (аналог таллия-201), позволяющего визуализировать дефекты перфузии миокарда как результат нарушенного коронарного резерва в ответ на повышенные метаболические потребности миокарда. Приступы стенокардии могут возникать достаточно часто - несколько раз в неделю, но при этом иметь стабильный характер. Таким образом, МВС является формой хронической стенокардии и по МКБ-10 относится к коду 120.8 «Другие формы стенокардии». Диагноз формулируется в зависимости от функционального класса стенокардии, например «ИБС при неизмененных коронарных артериях. Стенокардия ФК II. (Микроваскулярная стенокардия)».
The main cause of MVS is dysfunction of the coronary microvessels, defined as an abnormal response of the coronary microcirculation to vasoconstrictor and vasodilating stimuli. Figure 1 shows the main mechanisms and signaling pathways of coronary blood flow regulation. Endothelial dysfunction, hyperreactivity of smooth muscle cells and increased activity of the sympathetic nervous system are discussed as the main causes of microvascular dysfunction. Estrogen deficiency may contribute to the development of CSC through endothelial dysfunction (DE) in postmenopausal women. Known traditional risk factors for atherosclerosis, such as dyslipidemia, smoking, obesity, impaired carbohydrate metabolism, can also influence the development of coronary endothelial dysfunction with the subsequent development of MVS.
The coronary reserve, defined as the ratio of myocardial blood flow in the hyperemia phase to basal blood flow, decreases if the basal blood flow is increased or reduced in the hyperemia phase. Basal blood flow correlates with hemodynamic parameters (blood pressure, neurohumoral parameters, myocardial metabolism, heart rate - heart rate). Recently, data have been obtained on the presence of delayed reuptake of norepinephrine in synapses in women, which may explain the specificity of MVS for women and impaired autonomic regulation of microvascular tone with a decrease in coronary reserve. On the contrary, the hyperemic response is regulated by endothelium-dependent and endothelium-independent reactions. The mechanisms that cause damage to hyperemic myocardial blood flow in patients with MVS are currently not clarified: some patients demonstrate endothelial dysfunction, others - an anomaly of endothelium-independent vasodilating reactions, in particular, adenosine metabolism defect. We have demonstrated for the first time a decrease in myocardial perfusion reserve during myocardial ATP-SPECT (Fig. 2) . It is possible to use dipyridamole to assess coronary reserve using transthoracic Doppler ultrasound (Fig. 3), and convincing evidence in favor of a decrease in coronary reserve has been obtained in studies using positron emission tomography of the heart.
Ischemic ECG changes and defects in thallium uptake by the myocardium during stress tests are identical in patients with MVS and obstructive atherosclerosis of epicardial coronary arteries, but differ in the absence of hypokinesis zones in MVS, which is due to small volumes of ischemic foci, their frequent localization in the subendocardial zone, and rapid washout of anaerobic metabolites and the appearance of zones with compensatory hypercontractility of adjacent myocytes, which significantly limits the possibility of visualizing such zones with impaired contractility. Nevertheless, the compensatory release of adenosine may be sufficient to stimulate the afferent fibers that cause the sensation of pain, which is especially pronounced in conditions of increased pain sensitivity, which characterizes patients with MVS.
MVS, as noted above, is established in the presence of angina attacks, documented myocardial ischemia in the absence of hemodynamically significant stenoses in the coronary artery (stenoses ≤50% or intact coronary arteries) and the absence of signs of vasospasm (as occurs with Prinzmetal's variant angina). Myocardial ischemia is usually documented by exercise tests, which are bicycle ergometry (VEM), treadmill test, or 24-hour Holter ECG monitoring (HM-ECG) by detecting horizontal ST segment depression more than 1 mm from the J point on the ECG. It should be considered unacceptable, practiced by doctors, the method of excluding the diagnosis of "IHD" only by identifying unchanged coronary arteries according to CAG in patients with pain in the chest, refusing to conduct additional research methods that most accurately verify myocardial ischemia, t.to. this leads to an underestimation of the symptoms of angina pectoris and the failure to prescribe the necessary drug therapy, which worsens the course of the disease and requires repeated hospitalizations. Thus, reliable verification of myocardial ischemia in patients with CSC seems to be a determinant that determines the strategy and tactics of treatment, and hence the prognosis of life in this group of patients.
Patients with MVS are characterized by low reproducibility of ischemic changes on the ECG during exercise tests and the almost inability to identify zones of hypokinesis according to stress echocardiography, which is due to the development of subendocardial ischemia due to spasm of intramyocardial vessels, in contrast to patients with obstructive atherosclerosis of the epicardial arteries, corresponding to transmural ischemia and systolic myocardial dysfunction.
Verification of myocardial ischemia in this group of patients is possible:
1) when visualizing myocardial perfusion defects in exercise or pharmacological tests;
2) confirmation by biochemical methods of metabolic disorders in the myocardium.
Due to the complexity of the latter technique, the fundamental methods for verifying myocardial ischemia in patients with MVS are:
1. Single photon emission computed tomography of the heart, combined with a VEM test or a pharmaceutical test. In the first case, upon reaching a submaximal heart rate (HR) or ECG signs of myocardial ischemia during the VEM test, patients are injected intravenously with 99mTc-MIBI (99mTc-methoxyisobutylisonitrile) with an activity of 185-370 mBq, followed by myocardial SPECT and assessment perfusion defects. In cases with insufficient information content of the exercise test or with its negative results, an alternative method for conducting radionuclide studies of myocardial perfusion is the method using a pharmacological test. In this case, the VEM test is replaced by intravenous administration of a pharmaceutical preparation (dobutamine, dipyridamole, adenosine). Previously, studies were carried out at the Federal State Budgetary Institution RKNPK of the Ministry of Health of Russia with the introduction of acetylcholine intracoronary and 99mTc-MIBI intravenously in order to provoke myocardial ischemia due to endothelial dysfunction. These data were subsequently confirmed in the ACOVA study. This method has demonstrated high information content, but has not found wide application due to its invasive nature. The use of dobutamine seems to be inappropriate in patients with MVS, because the expected effects of reducing myocardial contractility due to ischemia will be extremely rare, as in the case of stress echocardiography. Currently, studies conducted at the Federal State Budgetary Institution RKNPC of the Ministry of Health of Russia make it possible to recommend in wide clinical practice a method for verifying myocardial ischemia in patients with MVS - myocardial SPECT, combined with the introduction of adenosine triphosphate (ATP) available on the pharmaceutical market of the Russian Federation.
2. Intracoronary administration of adenosine with assessment of blood flow velocity by intravascular ultrasound proves the presence of abnormal blood flow velocity in patients with MVS.
3. Abnormal ratio of phosphocreatine / ATP in the myocardium in patients with MVS according to MR spectroscopy.
4. Subendocardial perfusion defects according to MRI of the heart.
In the treatment of all patients with MVS, the optimal level of risk factors should be achieved. The selection of symptomatic therapy is empirical in nature due to the unspecified cause of the disease. The results of clinical trials cannot be generalized due to the lack of uniform selection criteria and the small number of patient samples, imperfect study design, and failure to achieve the effectiveness of MVS treatment.
Traditional antianginal drugs are prescribed at the first stages of treatment. Short-acting nitrates are recommended for the relief of anginal attacks, but they often have no effect. In connection with the dominant symptomatology of angina pectoris, therapy with β-blockers seems rational, the positive effect of which on the elimination of angina symptoms has been proven in several studies; these are the drugs of first choice, especially in patients with obvious signs of increased adrenergic activity (high pulse rate at rest or during exercise).
Calcium antagonists and long-acting nitrates have shown mixed results in clinical trials, and their efficacy is evident when added to β-blockers in cases of persistent angina. Calcium antagonists may be recommended as first-line drugs in case of variability in the threshold for angina pectoris. In patients with persistent angina despite optimal antianginal therapy, the following prescriptions may be suggested. ACE inhibitors (or angiotensin II blockers) can improve microvascular function by neutralizing the vasoconstrictor effect of angiotensin II, especially in patients with arterial hypertension and diabetes mellitus. Perhaps the appointment of some patients in order to suppress the increased sympathetic activity of α-blockers, the effect of which on the symptoms of angina pectoris remains unclear. An improvement in exercise tolerance in patients with MVS has been demonstrated during nicorandil therapy.
Improvement in clinical symptoms was achieved by correcting endothelial function during statin therapy and estrogen replacement therapy. Patients with persistent angina during therapy with the drugs mentioned above may be offered treatment with xanthine derivatives (aminophylline, bamiphylline) in addition to antianginal drugs to block adenosine receptors. New antianginal drugs - ranolazine and ivabradine - also demonstrated efficacy in patients with MVS (Table 1). Finally, in the case of refractory angina, additional interventions (eg, transcutaneous neurostimulation) should be discussed.

Literature
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3. Sharaf B.L., Pepine C.J., Kerensky R.A. et al. Detailed angiographic analysis of women with suspected ischemic chest pain (pilot phase data from the NHLBI-sponsored Women’s Ischemia Syndrome Evaluation Study Angiographic Core Laboratory // Am. J. Cardiol. 2001. Vol. 87. P. 937-941.
4. Johnson B.D., Shaw L.J., Buchthal S.D. et al. Prognosis in women with myocardial ischemia in the absence of obstructive coronary disease. Results from the National Institutes of Health-National Heart, Lung, and Blood Institute-sponsored Women’s Ischemia Syndrome Evaluation (WISE) // Circulation. 2004 Vol. 109. P. 2993-2999.
5. Jespersen L., Hvelplund A., Abildstrøm S.Z. et al. Stable angina pectoris with no obstructive coronary artery disease is associated with increased risks of major adverse cardiovascular events // Eur. Heart J. 2012. Vol. 33. P. 734-744.
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11. Patent for invention: A method for diagnosing myocardial ischemia in patients with Cardiac Syndrome X according to single photon emission computed tomography with 99mTc-MIBI in combination with a pharmacological test with sodium adenosine triphosphate. Application N 2012122649, decision to grant a patent dated July 22, 2013. G.N. Soboleva, L.E. Samoilenko, I.E. Karpova, V.B. Sergienko, Yu.A. Karpov.
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13. Zeiher A.M., Krause T., Schachinger V. et al. Impaired endothelial-dependent vasodilatation of coronary resistance vessels is associated with exercise induced myocardial ischemia // Circulation. 1995 Vol. 91. P. 2345-2352.
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Lupanov V.P.

December 2012 G. published in the Journal of the American College of Cardiology new practical recommendations By diagnostics And treatment sick stable ischemic sickness hearts(CHS).

To the editorial committee for the preparation recommendations entered: American College of Cardiology (ACCF), American association hearts(A.H.A.) American College of Physicians (ACP), American Association for Thoracic Surgery (AATS), Preventive Nurses Association (PCNA), Society for Cardiovascular Angiography and Interventional Interventions (SCAI), Society for Thoracic Surgeons (STS). Recommendations contain 120 pages, 6 chapters. 4 appendices, bibliography - 1266 sources.

IN chapter 4 of these recommendations issues considered medical treatment stable ischemic heart disease. This article only deals with questions medical treatment stable ischemic heart disease.

Recommendations By treatment stable IHD should help practitioners make the right decisions in various clinical situations. To do this, it is important to navigate the class of recommendations (I, II, III) and levels of evidence (A, B, C) of each of the recommended interventions (Table 1).

Patients with stable IBS should be carried out treatment according to the recommendations (guidelines) directed medical therapy - guideline-directed medical therapy (GDMT) (a new term meaning optimal medical therapy as defined by ACCF/AHA; First of all, this applies to class I recommendations).

Diet, weight loss and regular physical activity;

If the patient is a smoker - stop smoking;

Reception of acetylsalicylic acid (ASA) 75-162 mg daily;

Taking statins in moderate doses;

If the patient hypertensive- antihypertensive therapy until BP is reached<140/90 мм рт.ст.;

If the patient is diabetic - proper control glycemia .

Traditional modifiable risk factors for CHD - smoking, hypertension, dyslipidemia, diabetes mellitus and obesity - are observed in most patients and are associated with high coronary risk. Therefore, the impact on the main risk factors: diet control, exercise, treatment diabetes, hypertension and dyslipidemia (4.4.1.1), smoking cessation and weight loss should be part of the overall strategy treatment all patients stable ischemic heart disease.

4.4.1. Modification of risk factors

4.4.1.1. Effect on blood lipids

1. Lifestyle modification, including daily physical activity, is highly recommended for all patients with stable IHD (level of evidence B).

2. Dietary therapy for all patients should include reduction of saturated fat intake (<7% от общей калорийности), трансжирных кислот (<1% от общей калорийности) и общего холестерина (<200 мг/дл) (уровень доказательности В).

3. In addition to therapeutic lifestyle changes, moderate or high doses of statins should be prescribed in the absence of contraindications and documented side effects (Evidence A).

1. For patients who cannot tolerate statins, low-density lipoprotein cholesterol reduction with bile acid sequestrants (FFS)*, niacin**, or a combination of both is reasonable (Evidence B).

Here is a summary American clinical guidelines consisting of medical therapy to prevent myocardial infarction and death (4.4.2); and therapy to relieve syndromes (4.4.3).

additional drug therapy to prevent

myocardial infarction and death

in patients stable ischemic heart disease

4.4.2.1. Antiplatelet therapy

1. Treatment ASA at a dose of 75-162 mg daily should be continued indefinitely in the absence of contraindications in patients with stable IHD (level of evidence A).

2. Treatment clopidogrel is reasonable in cases where ASA is contraindicated in patients with stable IHD (level of evidence B).

1. Treatment ASA at doses of 75 to 162 mg daily and clopidogrel 75 mg daily. may be reasonable in some patients with stable high-risk CAD (Evidence B).

4.4.2.2. Therapy with b-blockers

1. Beta-blocker therapy should be started and continued for 3 years in all patients with normal left ventricular function after myocardial infarction or acute coronary syndrome (Evidence B).

2. β-blockers should be used in all patients with left ventricular systolic dysfunction (EF≤40%), heart failure, or prior to myocardial infarction, unless contraindicated (carvedilol, metoprolol succinate, or bisoprolol are recommended and have been shown to reduce the risk of death (level of evidence A).

1. β-blockers may be considered as chronic therapy for all other patients with CAD or other vascular disease (Evidence C).

4.4.2.3. ACE inhibitors and blockers

angiotensin receptors

(renin-angiotensin-aldosterone blockers)

1. ACE inhibitors should be given to all patients with stable CAD who also have hypertension, diabetes mellitus, LVEF 40% or less, or chronic kidney disease, unless contraindicated (Evidence A).

2. Angiotensin receptor blockers are recommended for patients with stable CAD who have hypertension, diabetes mellitus, left ventricular systolic dysfunction or chronic kidney disease and are indications for ACE inhibitors but cannot tolerate them (Evidence A).

1. Treatment with an ACE inhibitor is reasonable in patients with both stable CAD and other vascular disease (Evidence B).

2. Angiotensin receptor blockers should also be used in other patients who cannot tolerate ACE inhibitors (Evidence level C).

4.4.2.4. Influenza vaccination

4.4.2.5. Additional therapy to reduce the risk of myocardial infarction and death

Class III. Benefit not proven.

3. Treatment of elevated homocysteine ​​with folic acid, vitamins B6 and B12 to reduce CV risk or improve clinical outcomes in patients with stable CAD is not recommended (Evidence A).

4. Chelation therapy (intravenous EDTA - ethylene diamine tetraacetic acid) to improve symptoms or reduce cardiovascular risk in patients with stable CAD is not recommended (level of evidence C).

5. Treatment with garlic, coenzyme Q10, selenium, and chromium to reduce CV risk or improve clinical outcomes in patients with stable CAD is not recommended (Evidence C).

4.4.3. Medical therapy

to relieve symptoms

4.4.3.1. Therapy with anti-ischemic

drugs

1. β-blockers should be given as initial therapy for symptomatic relief in patients with stable CAD (Evidence B).

2. Calcium channel blockers or long-acting nitrates should be given for symptomatic relief when β-blockers are contraindicated or cause unacceptable side effects in patients with stable CAD (Evidence B).

3. Calcium channel blockers or long-acting nitrates in combination with β-blockers should be given to relieve symptoms when initial therapy with β-blockers is not effective in patients with stable CAD (Evidence B).

4. Sublingual nitroglycerin or nitroglycerin spray is recommended for immediate relief of angina in patients with stable CAD (Evidence B).

1. Treatment with a long-acting non-dihydropyridine calcium channel blocker (verapamil or diltiazem) is reasonable for symptom relief when β-blockers are not effective as initial therapy in patients with stable CAD (Evidence B).

2. Treatment with ranolazine may be useful when given as a substitute for a β-blocker to relieve symptoms in patients with stable CAD, if initial β-blocker treatment results in unacceptable side effects or is ineffective, or initial β-blocker treatment is contraindicated ( level of evidence B).

3. Treatment with ranolazine in combination with a β-blocker in patients with stable CAD may be useful in relieving symptoms when initial β-blocker monotherapy fails (Evidence A).

Consider antianginal drugs that are used or not approved for use in the US in new American guidelines for the treatment of stable coronary artery disease 2012 d. Different Levels of Evidence of Effectiveness new pharmacological agents in general vary greatly, the drugs are not without side effects, especially in elderly patients and when combined with other drugs.

4.4.3.1.4. Ranolazine is a partial inhibitor of fatty acid oxidation, which has antianginal properties. It is a selective inhibitor of late sodium channels, which prevent intracellular calcium overload, a negative factor in myocardial ischemia. Ranolazine reduces contractility, stiffness of the myocardial wall, has an anti-ischemic effect and improves myocardial perfusion without changing heart rate and blood pressure. The antianginal efficacy of ranolazine has been shown in three studies in IHD patients with stable angina (MARISA, CARISA, ERICA). Metabolic drug that reduces myocardial oxygen demand, it is indicated for use in combination with traditional antianginal therapy in those patients who remain symptomatic when taking traditional drugs. Compared with placebo, ranolazine reduced the frequency of angina attacks and increased exercise tolerance in a large study in patients with angina who had experienced acute coronary syndrome (MERLIN-TIMI) .

Since 2006, ranolazine has been used in the USA and in most European countries. When taking the drug, there may be a prolongation of the QT interval on the ECG (approximately 6 milliseconds at the maximum recommended dose), although this is not considered responsible for the phenomenon of torsades de pointes, especially in patients who experience dizziness. Ranolazine also reduces glycated hemoglobin (HbA1c) in patients with diabetes mellitus, but the mechanism and consequences of this have not yet been established. Combination therapy with ranolazine (1000 mg 2 times / day) with simvastatin increases the plasma concentration of simvastatin and its active metabolite by 2 times. Ranolazine is well tolerated, side effects - constipation, nausea, dizziness and headache - are rare. The frequency of syncope when taking ranolazine is less than 1%.

4.4.3.1.5.1. Nicorandil. The nicorandil molecule contains a nitrate group and a residue of nicotinic acid amide, therefore it has the properties of organic nitrates and activators of adenosine triphosphate-dependent potassium channels. The drug balances preload and afterload on the myocardium. By opening ATP-dependent potassium channels, nicorandil fully reproduces the effect ischemic preconditioning: promotes energy conservation in the heart muscle and prevents the necessary cellular changes in conditions of ischemia. It has also been proven that nicorandil reduces platelet aggregation, stabilizes coronary plaque, normalizes endothelial function and sympathetic nervous activity in heart. Nicorandil does not cause the development of tolerance, does not affect heart rate and blood pressure, conduction and contractility of the myocardium, lipid metabolism and glucose metabolism. Nicorandil is recommended for use in the European guidelines (2006) and the recommendations of the VNOK (2008) as monotherapy for intolerance or contraindications to β-blockers or calcium antagonists, or as an additional drug for their insufficient effectiveness.

The antianginal activity of nicorandil has been demonstrated in many studies. Its prognostic benefit has been shown in comparison with placebo in patients with coronary sickness hearts in the IONA study. In this study (n=5126, follow-up 12-36 months), significant benefits in the treatment group (20 mg twice daily) were found across several composite measures, including the primary endpoint (CHD death, non-fatal MI or unplanned hospitalization for CAD: hazard ratio 0.83, 95% confidence interval 0.72-0.97; p = 0.014). This positive result was mainly due to a decrease in acute coronary events. Interestingly, in this study, treatment with nicorandil was not associated with a reduction in symptoms as assessed by the Canadian classification.

The main side effect of nicorandil is headache at the beginning of treatment (discontinuation rate 3.5-9.5%), which can be avoided by gradually increasing the dose to the optimal level. Perhaps the development of allergic reactions, skin rash, itching, gastrointestinal symptoms. Occasionally, undesirable effects such as dizziness, malaise and fatigue develop. Ulceration was first described in the oral cavity (aphthous stomatitis) and was rare. However, in subsequent studies, a few cases of perianal, colonic, vulvovaginal, and groin ulceration have been described, which can be very serious, although always reversible upon discontinuation of treatment. Nicorandil is included in the first Russian National Guidelines for Cardiovascular Prevention: recommendation class I, level of evidence B.

4.4.3.1.5.2. Ivabradin. New a class of antianginal agents - inhibitors of the activity of sinus node cells (ivabradine) - has a pronounced selective ability to block If-ion channels, which are responsible for the sinoatrial pacemaker and cause a slowdown in heart rate. Currently, ivabradine is the only pulse-slowing drug used in the clinic, which realizes its effects at the level of the pacemaker cells of the sinoatrial node, i.e. is a true blocker of If-currents. Ivabradine can be used in patients with stable angina pectoris with sinus rhythm, both with intolerance or contraindications to the use of β-blockers, and for combined use with β-blockers, if the latter do not control heart rate (more than 70 beats / min.), And increasing their dose is impossible . In chronic stable angina, the drug at a dose of 5-10 mg / day. lowers heart rate and myocardial oxygen demand without negative inotropic action. Further trials of the drug are ongoing, including in patients with refractory angina and chronic heart failure. One of the side effects of ivabradine is the induction of phosphene-disturbances in light perception (luminous dots, various figures that appear in the dark) associated with changes in the retina. The frequency of eye symptoms is about 1%, they disappear on their own (in the first 2 months of treatment in 77% of patients) or when you stop taking ivabradine. Possible excessive bradycardia (frequency of occurrence - 2% at the recommended dose of 7.5 mg 2 times / day.). Thus, new pharmacological agents - ivabradine, nicorandil, ranolazine - may be effective in some patients with angina pectoris, but additional clinical trials are needed.

4.4.3.1.5.3. Trimetazidine. The anti-ischemic effect of trimetazidine is based on its ability to increase the synthesis of adenosine triphosphoric acid in cardiomyocytes with insufficient oxygen supply due to a partial switch in myocardial metabolism from fatty acid oxidation to a less oxygen-consuming pathway - glucose oxidation. This increases the coronary reserve, although the antianginal effect of trimetazidine is not due to a decrease in heart rate, a decrease in myocardial contractility, or vasodilation. Trimetazidine is able to reduce myocardial ischemia in the early stages of its development (at the level of metabolic disorders) and thereby prevent the occurrence of its later manifestations - anginal pain, rhythm disturbances hearts. decrease in myocardial contractility.

A meta-analysis by the Cochrane Collaboration grouped trials of trimetazidine versus placebo or other antianginal drugs in patients with stable angina. The analysis showed that, compared with placebo, trimetazidine significantly reduced the frequency of weekly angina attacks, nitrate intake, and the time to onset of severe ST segment depression during exercise tests. The antianginal and anti-ischemic efficacy of trimetazidine, taken in combination with β-blockers, is superior to that of long-acting nitrates and calcium antagonists. The severity of the positive effect of trimetazidine increases as the duration of treatment increases. Additional benefits of drug therapy may be obtained in patients with left ventricular systolic dysfunction. ischemic nature, including after acute myocardial infarction. The use of trimetazidine before surgical interventions on the coronary arteries (PCI, CABG) can reduce the severity of myocardial damage during their implementation. Long-term treatment with trimetazidine after surgery reduces the likelihood of recurrence of angina attacks and the frequency of hospitalizations for acute coronary syndrome, reduces the severity of ischemia, improves exercise tolerance and quality of life. The results of clinical studies and their meta-analyses confirm the good tolerability of trimetazidine therapy, which is superior to that of hemodynamically active ananginal drugs. Trimetazidine can be used either as an addition to standard therapy or as a substitute for it if it is not well tolerated. The drug is not used in the United States, but is widely used in Europe, Russia and more than 80 countries around the world.

Conclusion

Stable angina pectoris (taking into account persons who have previously had a myocardial infarction) is one of the most common forms of coronary artery disease. It is estimated that the number of people suffering from angina pectoris is 30-40 thousand per 1 million population. In the United States, more than 13 million patients with coronary sickness hearts. of these, about 9 million have angina pectoris.

The main goals of treating angina pectoris are to relieve pain and prevent the progression of the disease by reducing cardiovascular complications.

The American guidelines define treatment success. The primary goals of treating patients with stable CAD are to minimize the chance of death while maintaining good health and function. hearts. The most specific goals are: reduction of premature cardiac death; prevention of complications of stable coronary heart disease, which directly or indirectly lead to a deterioration in functional ability, including non-fatal myocardial infarction and heart failure; maintaining or restoring a level of activity, functional ability and quality of life that satisfies the patient; complete or almost complete elimination of symptoms of ischemia; minimizing the cost of maintaining health, reducing the frequency of hospitalizations and conducting repeated (often unreasonable) functional methods of research and treatment, reducing the side effects of excessive prescriptions of drugs and examination methods.

Doctors are accustomed to conducting symptomatic therapy aimed at relieving angina attacks, reducing shortness of breath or swelling, lowering blood pressure or heart rate to normal levels. However, strategic thinking is also necessary at the bedside: one should think about the long-term prognosis, assess the risk of possible death and severe complications. disease. try to achieve the target levels of the main indicators of blood lipids, biochemical parameters and markers of inflammation, normalization of body weight of patients, etc. .

As shown in the new American guidelines, strategic therapy with statins, ASA, and, when indicated, taking β-blockers, ACE inhibitors, or angiotensin II receptor antagonists, just provides a real and reliable opportunity to reduce mortality and improve the course of coronary artery disease. Patients should definitely know that the ultimate goal of using these drugs is to prevent premature death and radically improve the course of disease and prognosis, and for this it is necessary to use these drugs for a long time (at least for 3-5 years). Individual therapy of patients at high risk (which includes patients with angina pectoris) differs from the general population by increasing efforts to prevent risk factors (from the appearance to reduction of their severity).

In recent years, along with traditional classes of drugs, such as nitrates (and their derivatives), β-blockers, calcium channel blockers, other drugs with different mechanisms of action (trimetazidine, ivabradine, partly nicorandil), as well as a new a drug (ranolazine) recently approved in the United States that reduces myocardial ischemia and is a useful adjunct to treatment. The American recommendations also indicate those drugs (class III), the use of which does not alleviate the course of stable coronary artery disease and improve the prognosis of patients.

Literature

1.Fihn S.D. Cardin J.M. Abrams J. et al. 2012 ACCF/AHA/ACP/FCP/AATS/PCNA/SCAI/SNS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease // J. Am. Coll. cardiol. 2012 . Vol.60 No. 24. P. e44-e164.

2. Nash D.N. Nash S.D. Ranolazine for chronic stable angina // Lancet. 2008 Vol. 372. P. 1335-1341.

3. Stone P.Y. The Anti-Ischemic Mechanism of Action of Ranolazine in Stable Ischemic Heart Disease // JACC. 2010 Vol. 56(12). P. 934-942.

4. Lupanov V.P. Ranolazine at ischemic disease hearts// Rational pharmacotherapy in cardiology. - 2012 . - T. 8, No. 1. - S. 103-109.

5. Wilson S.R. Scirica B.M. Braunwald E. et al. Efficacy of ranolazine in patients with chronic angina observations from the randomized, double-blind, placebo-controlled MERLIN-TIMI (Metabolic Efficiency With Ranolazine for Less Ischemia in Non-ST-Segment Elevation Acute Coronary Syndromes) 36 Trial // J. Am. Coll. cardiol. 2009 Vol. 53(17). P. 1510-1516.

6. Di Monaco. Sestito A. The patient with chronic ischemic heart disease. Role of ranolazine in management of stable angina // Eur. Rev. Med. Pharmacol. sci. 2012. Vol. 16(12). P. 1611-1636.

7 Timmis A.D. Chaitman B.R. Crager M. Effects of ranolazine on exercise tolerance and HbA1c in patients with angina and diabetes // Eur. Heart J. 2006. Vol. 27. P. 42-48.

8. Gayet J-L. Paganelli F. Conen-Solal A.F. Update on the medical treatment of stable angina // Arch. Cardiovasc. Dis. 2011 Vol. 104. P. 536-554.

9. Horinaka S. Use of Nicorandil in cardiovascular disease and its optimization // Drugs. 2011 Vol. 71, no. 9. P. 1105-1119.

10. Lupanov V.P. Maksimenko A.V. Protective ischemia in cardiology. Forms of myocardial conditioning (review) // Cardiovasc. therapy and prevention. - 2011. - No. 10(1). - S. 96-103.

11. Lupanov V.P. The use of nicorandil, an activator of potassium channels, in the treatment of patients with ischemic sickness hearts// Handbook of the polyclinic doctor. - 2011. - No. 8. - S. 44-48.

12. IONA Study Group. Effect of nicorandil on coronary events in patients with stable angina: the Impact Of Nicorandil in Angina (IONA) randomised trial // Lancet. 2002 Vol. 359. P. 1269-1275.

13. Cardiovascular prevention. National recommendations of VNOK // Cardiovasc. therapy and prevention. - 2011. - No. 10(6); App.2. - S. 57.

14. Tendera M. Borer J.S. Tardif J.C. Efficacy of I(f) inhibition with ivabradine in different subpopulations with stable angina pectoris // Cardiol. 2009 Vol. 114(2). P. 116-125.

15. Aronov D.M. Arutyunov G.P. Belenkov Yu.N. Agreed opinion of experts on the advisability of using the myocardial cytoprotector trimetazidine (Preductal MB) in the complex therapy of patients with chronic forms ischemic disease hearts// Cardiosomatics. - 2012. - T. 3, No. 2. - C. 58-60.

16. Lupanov V.P. Trimetazidine MB in patients with ischemic sickness heart (review) // Consilium Med. - 2010. - T. 12, No. 1. - C. 5-11.

17. Ciapponi A. Pizarro R. Harrison J. Trimetazidine for stable angina // Cochrane Database Syst. Rev. 2005: CD003614.

18. Aronov D.M. Lupanov V.P. atherosclerosis and coronary disease hearts. Second edition, revised. - M. Triada X, 2009. - 248 p.

National guidelines for the prevention, diagnosis and treatment of arterial hypertension

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The recommendations were developed by experts of the All-Russian Scientific Society of Cardiology in 2001 and approved at the Russian National Congress of Cardiology on October 11, 2001. The second revision of the Recommendations was carried out in 2004.

Committee of experts for the development of recommendations for the diagnosis and treatment of arterial hypertension: Belousov Yu.B. (Moscow), Borovkov N.N. (Nizhny Novgorod), Boytsov S.A. (Moscow), Britov A.N. (Moscow), Volkova E.G. (Chelyabinsk), Galyavich A.S. (Kazan), Glezer M.G. (Moscow), Grinshtein Yu.I. (Krasnoyarsk), Zadionchenko V.S. (Moscow), Kalev O.F. (Chelyabinsk), Karpov R.S. (Tomsk), Karpov Yu.A. (Moscow), Kobalava Zh.D. (Moscow), Kukharchuk V.V. (Moscow), Lopatin Yu.M. (Volgograd), Makolkin V.I. (Moscow), Mareev V.Yu. (Moscow), Martynov A.I. (Moscow), Moiseev V.S. (Moscow), Nebieridze D.V. (Moscow), Nedogoda S.V. (Volgograd), Nikitin Yu.P. (Novosibirsk), Oganov R.G. (Moscow), Ostroumova O.D. (Moscow), Olbinskaya L.I. (Moscow), Oshchepkova E.V. (Moscow), Pozdnyakov Yu.M. (Zhukovsky), Storozhakov G.I. (Moscow), Khirmanov V.N. (St. Petersburg), Chazova I.E. (Moscow), Shalaev (Tyumen), Shalnova S.A. (Moscow), Shestakova M.V. (Ryazan), Shlyakhto E.V. (St. Petersburg), Yakushin S.S. (Ryazan).

Dear colleagues!

The second version of the national recommendations for the prevention, diagnosis and treatment of arterial hypertension, as well as the first one, is the result of the joint work of experts from all regions of Russia. These recommendations are based on new data that have appeared since the publication of the first version in 2001. Based mainly on the results of large-scale international studies, they reflect current issues in the classification of arterial hypertension, the formulation of the diagnosis, as well as the algorithms of medical tactics. The recommendations are a concise and clear summary of current approaches to the prevention, diagnosis and treatment of arterial hypertension; they are intended primarily for use in practical public health. The All-Russian Scientific Society of Cardiology hopes that the introduction of improved recommendations will effectively change the state of the problem of diagnosing and treating arterial hypertension in Russia for the better.

President of the All-Russian Scientific Society of Cardiology,

Academician of RAMS

R. G. Oganov

Introduction

Since the publication of the first Russian recommendations in 2001 on the prevention, diagnosis and treatment of hypertension, new data have accumulated that require a revision of the recommendations. In this regard, at the initiative of the section of arterial hypertension of the VNOK and with the support of the Presidium of the VNOK, the second revision of the National Guidelines for the Prevention, Diagnosis and Treatment of Arterial Hypertension was developed and discussed. Well-known Russian specialists took part in them. At the congress of cardiologists in Tomsk, the second revision of the recommendations was officially approved.

Arterial hypertension (arterial hypertension) in the Russian Federation, as in all countries with developed economies, is one of the urgent medical and social problems. This is due to the high risk of complications, high prevalence and insufficient control in the population scale. In Western countries, blood pressure is properly controlled in less than 30% of the population, and in Russia in 17.5% of women and 5.7% of men with hypertension. The benefits of lowering blood pressure have been proven not only in a number of large, multicenter studies, but also in a real increase in life expectancy in Western Europe and the USA.

The second version of the recommendations was based on the European guidelines for the control of hypertension (2003). A feature of the second version, like the previous one, is that, in accordance with the current provisions set out in the latest European guidelines, hypertension is considered as one of the elements of the individual cardiovascular risk stratification system. AH, due to its pathogenetic significance and the possibility of regulation, is one of the most important components of this system. Such an approach to understanding the essence and role of hypertension as a risk factor can actually reduce CVD and mortality in Russia.

List of abbreviations and conventions

A - angiotensin

AV block - atrioventricular block

AG - arterial hypertension

BP - blood pressure

AIR - agonists of I 1 -imidazoline receptors

AK - calcium antagonists

ACS - associated clinical conditions

ACTH - adrenocorticotropic hormone

AO - abdominal obesity

ARP - renin activity in blood plasma

BA - bronchial asthma

BAB - beta-blockers

ACE inhibitors - angiotensin-converting inhibitors

enzyme

IHD - ischemic heart disease

MI - myocardial infarction

IMM LV - mass index of the myocardium of the left ventricle

BMI - body mass index

TIA - transient ischemic attack

Ultrasound - ultrasonography

FA - physical activity

FK - functional class

FN - physical activity

RF - risk factors

COPD - chronic obstructive pulmonary disease

CNS - central nervous system

ECG - electrocardiogram

EchoCG - echocardiography

Definition

The term "arterial hypertension" refers to the syndrome of increased blood pressure in "hypertension" and "symptomatic arterial hypertension".

The term "hypertension" (AH), proposed by G.F. Lang in 1948, corresponds to the concept of "essential hypertension" used in other countries.

Hypertension is commonly understood as a chronic disease, the main manifestation of which is hypertension, not associated with the presence of pathological processes, in which the increase in blood pressure is due to known, in modern conditions, often eliminated causes (“symptomatic arterial hypertension”). Due to the fact that AH is a heterogeneous disease that has fairly distinct clinical and pathogenetic variants with significantly different mechanisms of development at the initial stages, the concept of "arterial hypertension" is often used in the scientific literature instead of the term "hypertension".

Diagnostics

Diagnosis and examination of patients with hypertension are carried out in strict sequence, in accordance with the following tasks:

- determination of stability and degree of increase in blood pressure;

- exclusion of symptomatic hypertension or identification of its form;

- assessment of overall cardiovascular risk;

• identification of other risk factors for CVD and clinical conditions that may affect the prognosis and effectiveness of treatment; determination of a particular risk group in a patient;

diagnosis of POM and assessment of their severity.

Diagnosis of hypertension and subsequent examination includes the following steps:

• repeated measurements of blood pressure;
• collection of anamnesis;
• physical examination;
• laboratory and instrumental research methods: simpler at the first stage and complex at the second stage of the examination.

  Rules for measuring blood pressure

  The accuracy of blood pressure measurement and, accordingly, the guarantee of the diagnosis of hypertension, the determination of its degree, depend on compliance with the rules for measuring blood pressure.

  The following conditions are important for measuring blood pressure:

  Updated European Society of Cardiology Guidelines (2013) for the management of coronary heart disease and cardiovascular disease in patients with diabetes mellitus

  Summary. Changes have been made to the standards for the diagnosis and treatment of patients with coronary heart disease

  Participants of the European Society of Cardiology Congress, held from August 31 to September 4, 2013 in Amsterdam, the Netherlands, had the opportunity to briefly review the updated Guidelines for the diagnosis and treatment of stable coronary artery disease (CHD), as well as for the management of patients with diabetes mellitus or prediabetes and concomitant cardiovascular pathology.

  Both documents were presented on September 1, 2013 during the meeting of the European Society of Cardiology and include the following information for European cardiologists:

  • in patients with stable coronary artery disease, the functional component of coronary vascular disease plays a more significant role than before for stenting compared with the severity of angiographic data;
  • the assessment of the pretest probability (PTP) of diagnosing coronary artery disease has been updated to include more modern indicators compared to the 34-year-old Diamond and Forrester Chest Pain Prediction Rule;
  • for elderly patients with diabetes mellitus and cardiovascular pathology, the criteria for glycemic control are somewhat weakened in favor of the quality of life of patients;
  • in patients with diabetes mellitus and CAD with multiple coronary artery disease, coronary artery bypass grafting is the treatment of choice, but if the patient prefers stenting, eluting stents should be placed.

  The recommendations raise the importance of PTT for the diagnosis of stable CAD, as a "new set of pre-test probability parameters" has been developed. As before, they are based on the data of Diamond and Forrester in 1979. However, compared with 1979, the incidence of coronary artery stenosis in patients with angina pectoris has decreased significantly. However, the new criteria for PTP still focus on the characterization of anginal pain (typical angina versus atypical angina versus non-anginal retrosternal pain), age, and gender of the patient.

  For example, in a patient with suspected coronary artery disease, using the new criteria as presented in the presentation at the Congress, in PTT<15% следует искать другие причины и рассмотреть вероятность функциональной коронарной болезни. При средних значениях ПТВ (15%–85%) пациенту следует провести неинвазивное обследование. Если ПТВ высокая - >85%, establish the diagnosis of coronary artery disease. Patients with severe symptoms or "clinical presentation suggestive of high-risk coronary anatomy" should be treated according to the Guidelines.

  The guidelines also raise the profile of modern imaging technologies, especially cardiac magnetic resonance imaging and coronary computed tomography angiography (CTA), but with the need for a sober, critical approach. According to the authors of the new Guidelines, they tried to create a moderately conservative document, but "not as conservative as the 2012 American Guidelines and not as progressive as the NICE (National Institute for Health and Clinical Excellence) recommendations" 2010".

  According to the Guidelines, coronary CTA should be considered in stable CAD as an alternative to imaging stress technologies in patients with moderate PTT values ​​for stable CAD with expected high quality imaging data. It should also be considered in patients with moderate PTT values ​​for stable CAD after inconclusive exercise electrocardiography or imaging stress testing, and in patients with contraindications to stress testing if obtaining a complete diagnostic picture with coronary CTA is expected.

  Members of the working group for the preparation of the Recommendations also focus on the presence of three "forbidding" recommendations (ІІІС): do not evaluate calcification in asymptomatic patients; do not perform coronary CTA in asymptomatic patients as a screening test; do not perform coronary CTA with a high probability of vascular calcification.

  Also noteworthy is the perhaps more aggressive provision, compared to the 2012 American guidelines, that every patient seeking medical attention for chest pain should have an echocardiogram at first contact at rest.

  The guidelines also state that microvascular angina and vasospasm are much more common causes of angina than previously thought. The problem, according to the authors, is that most practitioners believe that coronary artery disease and, in particular, angina pectoris, are conditions caused by stenosis of the coronary arteries. Which, of course, is true, but does not exhaust all possible causes of the development of the disease.

  The Congress also presented updated recommendations for the treatment of stable coronary artery disease.

  Many patients are referred to catheterization laboratories without any symptoms of ischemia. Cardiac catheterization, as a method available in these laboratories, is used to measure blood flow in the coronary arteries - the so-called fractional blood flow reserve. A method for determining hemodynamically appropriate coronary artery disease in the absence of evidence of ischemia is classified as Class I, Evidence Level A. Intracoronary ultrasound or optical coherence tomography (CRI Class II, Evidence Level B) may be considered to characterize vascular lesions. and improve the efficiency of stenting.

  The guidelines have also contributed to a very tense debate between surgeons and interventional cardiologists vying for patients referred for coronary revascularization. Clear specific recommendations are formulated, mostly based on the SYNTAX score, which categorizes patients according to the severity of coronary artery disease, due to the anatomy of the coronary lesion.

  For example, in patients with clinically significant stenosis of the main left coronary artery - involving only one vessel - percutaneous coronary intervention (PCI) should be performed for stem or median lesions, however, if vascular lesions are localized distal to the bifurcation, a concilium decision of experts on the subject choice of PCI or coronary artery bypass grafting as a treatment option. In multivascular lesions, the SYNTAX scale should be used, with values<32 необходимо консилиумное решение, при значениях >33, coronary bypass surgery should be performed.

  There are no significant changes in the Guidelines regarding the medical treatment of stable coronary heart disease, except for the inclusion of three drugs that debuted as antianginal drugs: ranolazine, nicorandil and ivabradine - all as second-line drugs.

  New in the Guidelines for patients with diabetes mellitus with cardiovascular pathology or high cardiovascular risk are patient-centered approaches to therapy: less aggressive glycemic control in elderly patients and simplified diagnosis, which focuses on the determination of glycated hemoglobin or fasting blood glucose, with backup using a glucose tolerance test only in "cases of uncertainty".

  Attention is also focused on the advantages of coronary artery bypass grafting as a method of first choice when deciding whether to conduct revascularization compared to PCI, which has been preferred in recent years.

  Obviously, it takes quite a long time to reduce cardiovascular risk through glycemic control. According to the authors, when treating patients aged 70–80 years with multiple comorbidities, a doctor who intends to somewhat tighten glycemic control in this group of patients should clearly understand the goals he hopes to achieve. Tightening of glycemic control is often associated with an increase in the frequency of episodes of hypoglycemia and a deterioration in the quality of life with many restrictions in the patient's daily life. The tight glycemic control required for cardio- and retinoprotection is of no value if patients are constantly in a state of hypoglycemia.

  Extremely important, the authors believe, is an individual approach to the patient with a discussion of the desirability or undesirability for the patient of certain restrictions associated with treatment. This approach requires an open and honest discussion with the patient of all possible treatment options and ways to achieve therapeutic goals. With age, patients are less likely to adhere to strict glycemic control, taking into account all the difficulties that accompany it. Quality of life is a category that practitioners should not ignore.

  Another group of patients who would benefit from less aggressive glycemic control are patients with long-term diabetes mellitus and autonomic neuropathy. Such patients, as a rule, lose the ability to feel the symptoms of hypoglycemia and, if this condition develops, become more vulnerable to its negative effects. Therefore, tight glycemic control does not compensate for the risk of developing hypoglycemic conditions in this category of patients.

  With regard to revascularization, the authors of the Guidelines believe that the recently published results of the FREEDOM study convincingly demonstrated the benefits of coronary artery bypass grafting in patients with diabetes mellitus with CAD compared with PCI, even with the use of eluting stents. Thus, the changes in the updated Guidelines address the benefits of complete revascularization by performing bypass surgery using arterial grafts, when possible, compared to PCI. The patient may choose to undergo the PCI procedure, however, in such cases, the patient should be informed of the differences in morbidity and even mortality several years after bypass and stenting.