Diagnosis of coronary heart disease, classification, symptoms and treatment. Ischemic heart disease (CHD) - symptoms, causes, types and treatment of IHD

Coronary artery disease (CHD) is a pathological process during which damage is caused to the myocardium due to impaired blood flow in the coronary arteries. That is why medical terminology suggests another name for the disease - coronary heart disease. At the first stage of formation, the disease develops asymptomatically, and only after the patient may experience an attack of angina pectoris. Treatment of pathology can be carried out with the help of medications or surgery. Everything here determines the degree of damage to the pathology.

Risk factors

Like all internal organs, the heart cannot function without a blood supply. Two coronary arteries are responsible for delivering the required amount of blood to the myocardium. They arise from the aorta in the form of a crown, and then divide into small vessels. Those, in turn, are responsible for delivering blood to specific areas of the heart muscle.

There is no other way of blood supply to the myocardium, therefore, with thromboembolism of any small vessel, oxygen starvation of the heart occurs, and this already leads to the formation coronary disease hearts.

Coronary artery disease is considered to be the underlying cause of coronary heart disease. It is characterized by overlapping cholesterol plaques or narrowing of the heart arteries. Therefore, the heart does not receive the necessary amount of blood for its normal functioning.

Symptoms

Symptoms of coronary heart disease begin to make themselves felt gradually. The first signs of a lack of oxygen to the myocardium can be recognized while running or walking fast. Violation of myocardial metabolism can be detected by such manifestations as chest pain when a person is at rest. The frequency of angina attacks depends on how much the lumen in the coronary artery has become smaller.

Together with angina pectoris, a person can visit chronic form. It is characterized by shortness of breath and increased swelling.

The lumen of the artery is completely closed when the plaque ruptures. These events can cause a heart attack or cardiac arrest. Here, the determining factor is the section of the heart muscle that has been affected. If a large artery is completely closed, then the patient will face serious consequences, even death.

The symptoms of coronary heart disease are very diverse and can manifest themselves in the clinical form that they accompany. Most often, the patient is visited by the following signs of coronary heart disease:

• chest pain affecting the left arm or shoulder;
• heaviness behind the sternum;
• apathy and shortness of breath.

If a person has been visited by the presented symptoms or there is at least one risk factor, then the doctor must ask him about the features pain syndrome and about the conditions that could provoke it.

As a rule, patients are aware of their illness and can accurately describe all the causes, the frequency of seizures, the intensity of pain, their duration and nature, taking into account physical activity or taking specific medications.

Varieties of coronary heart disease

Ischemic heart disease can be represented by various types. The classification of the disease is relevant and is used today by all doctors, despite the fact that it was developed in 1979. It presents individual forms of coronary heart disease, which are characterized by their symptoms, prognosis and therapy. Today, IHD has the following clinical forms:

1. Rapid coronary death.
2. Seizure.
3. Myocardial infarction.
4. Postinfarction cardiosclerosis.
5. Insufficient circulation.
6. Violation of the rhythm of the body.
7. Painless myocardial ischemia.
8. Microvascular ischemic heart disease.
9. New syndromes of ischemia.

Of all the described forms, most often patients are diagnosed with myocardial infarction, angina pectoris and rapid coronary death. Therefore, we will consider them in more detail.

angina pectoris

This disease is considered the most common symptom of coronary heart disease. Its development is associated with atherosclerotic damage to the vessels of the heart, resulting in blood clots and blockage of the lumen of the artery. Damaged vessels are not able to perform their direct duties of carrying blood, even if a person performs minor physical exertion. The result of this process is a disturbed metabolism, which is manifested by pain.

Signs of coronary heart disease in this case are as follows:

1. Pain in the chest, which has a paroxysmal character. They affect the left arm, shoulder, in some cases, the back, shoulder blade.
2. Violation of the rhythm of the heart.
3. Increase in blood pressure.
4. The occurrence of shortness of breath, feelings of anxiety, pallor of the skin.

Depending on what causes provoked angina pectoris, the following variants of its course are distinguished. She may be:

1. Tense, if it arose against the background of some kind of load. If you take nitroglycerin, then all the pain disappears.
2. Spontaneous angina pectoris is a form of coronary heart disease, which is characterized by the presence of pain without justified reasons and the absence of physical exertion.
3. Unstable angina is a form of coronary heart disease that is characterized by the progression of the disease. Here there is an increase in pain and an increased risk of acute myocardial infarction and death. The patient is increasingly using medication, as his condition has deteriorated significantly. With this form of the disease, immediate diagnosis and urgent therapy are required.

myocardial infarction

Ischemic heart disease often manifests itself in the form of myocardial infarction. Here, the necrosis of the muscle of the organ occurs due to the sudden cessation of blood supply to it. Most often, the disease affects men than women, and for the following reasons:

1. Atherosclerosis develops later in the female half of the population due to hormonal status. After the onset of menopause, there is a greater percentage of the likelihood of myocardial infarction. Already by the age of 70, the disease can affect both men and women equally.
2. Men drink more alcohol and smoke.

In addition to the risk factors presented, the following causes can contribute to the occurrence of myocardial infarction:

• violation of the coagulation and anticoagulation systems;
• insufficient development of "bypass" ways of blood circulation;
• violation of metabolism and immunity in combination with damage to the heart muscle.

This form of coronary artery disease is characterized by the death of the patient, which most often occurs in the presence of witnesses. It occurs instantly or within 6 hours from the time the heart attack occurred.

Coronary heart disease in this form is manifested by loss of consciousness, respiratory and cardiac arrest, dilated pupils. In this state of affairs, it is urgent to take therapeutic measures. If you immediately provide medical assistance to the victim, then he has a chance for life.

But, as practice shows, even timely resuscitation does not reduce the risk of death. In 80% of cases, the patient dies. This form of ischemia can affect young and old people. The reason is a sudden spasm of the coronary arteries.

Consequences of the disease

Ischemic heart disease due to untimely treatment can provoke many complications:

1. Postinfarction cardiosclerosis.
2. Chronic heart failure.
3. Acute heart failure.
4. Cardiogenic shock.

Therapeutic activities

How to treat coronary heart disease? Therapy of the disease implies a set of measures, thanks to which it is possible to normalize the delivery of the required amount of blood to the myocardium to eliminate the consequences. Therefore, the treatment of coronary heart disease involves drugs whose action is aimed at regenerating this balance.

Surgical treatment

When drug therapy fails positive result, the patient is prescribed surgical treatment of coronary heart disease. During the operation, the surgeon cleans the arteries from cholesterol.

There are situations when coronary heart disease occurs due to a slight hardening of platelets. Therefore, it is not possible to cite procedures such as stenting or angioplasty. If such a pathology occurs, you can try to remove a blood clot using a special medical device that looks like a drill. The effectiveness of such treatment of coronary heart disease is achieved when the vessel is affected in a separate area of ​​the artery.

Brachytherapy

Ischemic heart disease is a pathology that is actively treated today with the help of radiation. This technique is used in the case when secondary damage to the vessels of the organ occurred after angioplasty. Such treatment is prescribed when diagnosing a severe form of coronary artery disease.

The presented type of surgical therapy includes standard measures. It is advisable to carry it out when the causes of the disease are numerous blockages of the artery. The operation takes place using the blood capillaries of the internal mammary artery.

The essence of the operation is that the patient is connected to the device, thanks to which artificial blood circulation is carried out. It functions instead of the heart muscle at the time of surgery. The organ itself is forcibly stopped for a while. Such therapy is in great demand, since after it there are practically no complications. Decrease the number side effects when performing open heart surgery, it is possible, but it is not always possible to use such manipulation.

Minimally invasive coronary surgery

It is advisable to carry it out if the causes of IHD are blockage of the first and anterior coronary arteries. In this situation, the surgeon, instead of the damaged vessel, installs the artery that was taken from the victim from the chest. Such treatment does not involve a complete opening of the sternum.

The method of indirect myocardial revascularization with a laser

Such therapy is prescribed when surgery and angioplasty are not possible. During the operation, the heart muscle is pierced in several places using a laser. New ones are formed at the puncture sites. blood vessels. The operation can be performed as a separate therapy and as a systemic approach.

Ischemic heart disease is a very serious and dangerous disease, contributing to the formation of a large number of complications, one of which is a fatal outcome. The success of treatment depends on the form and severity of the disease. In this case, it is very important to determine the causes of the disease and its manifestations in time.

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Answer only if you have proven medical knowledge

Many people lose value as they get older. pain symptoms in the region of the heart, considering them a natural manifestation of the aging of the body.

Meanwhile, these signs may indicate the development of coronary disease, which is one of the leading causes of death worldwide. How to recognize formidable symptoms? And most importantly, what causes heart disease?

Ischemic disease is called functional or organic changes in the heart muscle leading to restriction or complete cessation of blood flow to certain areas.

That is, the main manifestation of the disease can be called an imbalance of the actual blood flow and the heart's need for blood supply.

The heart muscle, more than other organs, suffers from a shortage of incoming blood. This is due to the isolation of the heart by the inner shell - the muscle does not receive oxygen from the pumped blood, but is supplied with blood through the coronary arteries. Their defeat or narrowing leads to the onset of the disease.

The main causes of coronary heart disease and the occurrence of its first signs:

• the development of atherosclerosis, narrowing the lumen of blood vessels due to cholesterol plaques;
• thrombosis of the feeding vessel;
• prolonged spasm caused by a violation of nervous regulation;
• defective functioning of the mechanisms that expand the arteries;
• metabolic changes.

What does the medical treatment of myocardial infarction include? Read about it in our next one.

From what arises

There are quite a few reasons that can cause the development of pathology:

• high levels of harmful lipids in the blood, which we get mainly from animal products;
• arterial hypertension (the upper pressure indicator from 140 can be called a harbinger of the disease);
• sedentary lifestyle;
• obesity, which significantly increases the load on the heart;
• diabetes(it has been proven that in patients with diabetes for more than ten years, in most cases, IHD develops);
• smoking, leading to chronic vasoconstriction and oxygen deficiency in the blood;
• alcohol abuse;
• excessive physical activity;
• constant stress leading to increased pressure;
• increased blood clotting, provoking the formation of blood clots.

At-risk groups

In the development of coronary artery disease, factors play an important role, which we cannot change. Those at high risk of ischemia include those who meet the following characteristics:

• Male. Before reaching old age, men are significantly more likely to develop ischemia than women. This is due to the high levels of estrogen in female body that resist atherosclerotic changes. After the onset of menopause, the difference in the incidence of the disease disappears.
• hereditary predisposition. It has long been known that diagnosing cases of ischemia in the family significantly increases the risk of developing pathology in other family members.
• Elderly age. In men, the critical age occurs after 55 years; women are characterized by a sharp increase in the number of cases after 65 years.
• Long-term use hormonal drugs . Contraceptives increase the risk of blood clots, so with long-term use, the frequency of thrombosis increases significantly.

Complications of IHD

Statistics show that even with a half-constricted heart vessel, a person may not feel signs of cardiac pathology. Chest pain can only appear during moments of increased physical exertion and quickly pass in a calm state.

Such mild symptoms and lack of timely therapy can lead to the progression of the disease or its transition to an acute form:

• chronic heart failure;
• angina;
• Heart arythmy;
• myocardial necrosis;
• sudden death.

The prognosis largely depends on the severity of the disease - with myocardial infarction, mortality is much higher than with angina pectoris. In the same time it is not uncommon for a disease that did not bother a person to become sharply aggravated. Lethal outcome with a small lesion of the arteries of the heart is more than half of sudden deaths caused by coronary artery disease.

The ongoing therapy is also of great importance - regular intake of the drug prescribed by the doctor and compliance with other recommendations reduce the chances of an unfavorable outcome by half.

Ischemia prevention

Disease prevention can only be achieved an integrated approach and a radical change in lifestyle. These preventive measures are indicated not only for those who have been diagnosed with ischemia, but also for those who are simply at risk.

If you have several factors at once that can provoke the development of pathology, then prevention is a must for you:

• give up nicotine, which contributes to the formation of blood clots and plaques;
• reduce alcohol consumption;
• get rid of extra pounds that increase the load on all body systems;
• reduce the consumption of animal products, high in cholesterol;
• increase the intake of potassium and magnesium - minerals vital for the full functioning of the heart muscle;
• increase the physical activity necessary to strengthen the heart muscle;
• avoid stress that causes sudden jumps in blood pressure;
• you can resort to, but only with the permission of a doctor;
• be observed by a cardiologist to recognize deviations from the norm at the initial stage.

If you are diagnosed with coronary heart disease, do not forget that The diagnosis is not yet the final verdict. Elimination of adverse factors, causes and control of symptoms of coronary artery disease will help prevent dangerous consequences. Be examined by a specialist: after all, the sooner treatment is started, the better the result will be.

Coronary heart disease has taken a leading place in the list of the main problems of medicine in the XXI century. Pathology has become the main cause of death among the population in many countries of the world, including developed European ones. A certain downward trend in the popularity of coronary artery disease was observed in the United States at the end of the last century, but in general, the spread of the disease is observed among people of different ages and sexes.

Ischemic heart disease (CHD) is a general concept that combines acute and chronic pathological processes with similar pathogenesis. The key role in the formation of coronary artery disease is assigned to a violation of the coronary circulation, as a result of which the metabolic exchange in the heart muscle changes. In other words, the myocardium requires more oxygen and nutrients than it receives from the existing blood flow.

The course of IHD is divided into acute, in the form of myocardial infarction, and chronic, when the patient is disturbed by periodic attacks of angina pectoris.

A special role in determining the type and nature of the course of IHD is given to modern diagnostic methods. The patient's complaints, objective examination, laboratory parameters and results of instrumental methods are taken into account. All this makes it possible to make an accurate diagnosis and further prescribe effective treatment. Otherwise, a poor prognosis is given.

Video: Ischemic heart disease - causes, diagnosis, treatment

IHD classification

The disease is considered in various rubricators, classifiers and open databases. But the most commonly used is the International Classification of Diseases of the 9th and 10th revisions. According to ICD-10, IHD is under I20-I25 font, and in ICD-9 - under 410-414.

According to Wikipedia, the term "ischemic heart disease" comes from the Latin. morbus ischaemicus cordis from other Greek. ἴσχω - “I hold back, hold back” and αἷμα - “blood”.

In the IHD group, the following clinical forms are distinguished:

1. Angina, which in turn is divided into unstable and stable, or exertional angina.
2. Myocardial infarction (primary).
3. Myocardial infarction (repeated).
4. Previously transferred myocardial infarction, expressed in postinfarction cardiosclerosis.
5. Sudden coronary death, which can result in successful resuscitation and death.
6. Heart failure.

When making a diagnosis, the clinical form of the disease must be indicated, for example: “CHD: stable angina II FC”. Some clinical forms are considered in separate classifications, according to which the required designation is necessarily indicated in the final diagnosis.

Braunwald's classification of unstable angina

A - there is an external cause that increases ischemia. Secondary unstable angina B - there is no external cause of angina pectoris. Primary unstable angina C - occurs within 2 weeks after myocardial infarction. Post-infarction angina pectoris
I - new onset, progressive angina pectoris, without rest angina pectoris IA IB IC
II - angina at rest within a month, but not within the next 48 hours IIA IIB IIC
III - rest angina in the next 48 hours IIIA IIIB IIIC

In addition to the above classification, in the group of unstable angina, early post-infarction KS, progressive and first-time, as well as Prinzmetal, or variant, are distinguished.

The classification of myocardial infarction is very voluminous and is considered according to the stages of development, the scale and anatomy of the lesion, the location of the necrotic focus, and the course of the disease. In addition, there are more modern classifications developed on the basis of general considerations of European, American and worldwide cardiology communities.

Causes of coronary artery disease

The development of the disease is directly related to the insufficient amount of oxygen that enters the heart muscle. Due to oxygen starvation, the myocardium begins to lose the ability to perform its functions, and the larger the affected area, the more pronounced the clinic of the disease. In some cases, blood circulation in the coronary vessels stops so abruptly that an acute oxygen deficiency occurs with all the ensuing consequences.

Why does blood flow stop in the coronary vessels? One or more pathological mechanisms may be involved in this:

1. atherosclerosis and thrombosis.
2. Atherosclerosis of the coronary vessels.
3. Spasm of blood vessels.

There are also so-called extravascular etiological factors that contribute to the development of coronary artery disease. In some cases, an important role is played by risk factors that contribute to the manifestation of the clinical picture of a sluggish process.

Development factors

key etiological factor development of coronary artery disease is atherosclerosis. With this pathology, there is a narrowing of the lumen of the coronary arteries, due to which the needs of the myocardium for blood supply do not coincide with the real possibilities of the bloodstream.

With atherosclerosis, specific plaques are formed, which in some cases block the lumen of the vessel by 80%. Then myocardial infarction develops, or, as a “lighter” option, angina pectoris.

The formation of an atherosclerotic plaque does not occur all at once. This can take months or even years. At the beginning, low-density lipoproteins are deposited on the walls of the coronary vessels, which begin to gradually affect the epithelium located nearby.

Platelets and other blood cells accumulate at the site of the lesion, due to which the lumen of the vessel is blocked by an increasingly protruding part of the plaque. If the pathological formation occupies up to 50% of the lumen of the vessel, then the clinic of the disease is sluggish or not at all expressed. Otherwise, IHD develops in one clinical form or another.

Each coronary artery supplies blood to a specific area of ​​the myocardium. The farther from its distal end is the area of ​​the vessel affected by atherosclerosis, the more extensive ischemia or necrosis can be. If the mouth of the left coronary artery or the main trunk is involved in the pathological process, then the most severe ischemia of the heart muscle develops.

In addition to the developmental factors that lie inside the vessel, there are also extravasal causes. First of all, it is arterial hypertension, which most often provokes a spasm of the coronary vessels. The formation of IHD is promoted by frequent and severe tachycardia, as well as myocardial hypertrophy. In the last two cases, the need of the heart muscle for oxygen increases sharply and, if they are not satisfied, ischemia develops.

Risk factors

Modern scientists and leading clinicians attach great importance to the formation of IHD to predisposing circumstances. Against their background, with the highest probability, a pathological condition can develop with all the ensuing consequences. Risk factors for coronary artery disease are in many ways similar to those in atherosclerosis, which is associated with the direct involvement of atherosclerotic plaque in partial or complete blockage of the vessel lumen.

Coronary heart disease is associated with many risk factors (RF), so a kind of classification was required to streamline them for better perception.

1. Biological risk factors:

• Men get sick more often than women.
• In older people, atherosclerosis is more often determined, which means that the likelihood of myocardial ischemia is higher.
• Hereditary predispositions that contribute to the development of diabetes mellitus, hypertension, dyslipidemia, and hence coronary artery disease.

2. Anatomical, physiological and metabolic risk factors:

• Diabetes mellitus, mainly of the insulin-dependent type.
• Overweight and obesity.
• Arterial hypertension.
• An increased amount of lipids in the blood (hyperlipidemia) or a violation of the percentage of different types of lipids (dyslipidemia).

3. Behavioral risk factors:

• Wrong nutrition.
• Having bad habits, especially smoking and drinking alcohol.
• Hypodynamia or excessive physical activity.

Muscular-elastic hyperplasia of the intima of arteries, including coronary arteries, is another possible risk factor for the occurrence of coronary artery disease, but today it is under study. Changes in the vessels according to the type of hyperplasia are already determined among children, so there are assumptions about the contribution of such RF to the development of coronary artery disease at an older age. In addition, the role of the CDH13 gene and its mutation in the formation of ischemia is being studied, but so far this assumption has not been fully proven.

Types of IHD

In patients with coronary artery disease, such clinical forms as myocardial infarction and angina pectoris are most often determined. Other varieties are not so common, and they are more difficult to diagnose. Based on this, the clinic and course of myocardial infarction, angina pectoris, sudden coronary death and postinfarction cardiosclerosis will be considered.

myocardial infarction

Such a diagnosis can be established when there is myocardial necrosis confirmed by clinical, laboratory and instrumental methods. It can be small or large, but regardless of this, the patient should be sent to the intensive care unit as soon as possible.

• Large-focal myocardial infarction is characterized by pathognomonic changes that are determined on the ECG and during laboratory diagnostics. Of particular importance is the increase in serum lactate dehydrogenase, creatine kinase and a number of other proteins.

Such enzymes indicate the activity of the redox reaction taking place in the body. If normally these components are found only in cells, then when they are destroyed, proteins pass into the blood, therefore, by their quantity, one can indirectly judge the scale of necrosis.

• Small-focal myocardial infarction is often endured by patients “on their feet”, since the clinic may not be expressed, and changes in the ECG and in the analyzes are also not as critical as in the case of large-focal MI.

angina pectoris

The disease has a characteristic clinical sign - retrosternal pain, which can occur from any stress (physical or emotional). Pain can be felt as a burning sensation, heaviness, or severe discomfort, and often spreads along nerve fibers to other parts of the body (scapula, lower jaw, left arm.

The duration of an angina attack is most often 1-10 minutes, much less often - up to half an hour.

Another feature characteristic of angina pectoris is the relief of pain with nitroglycerin, which practically does not help with myocardial infarction. Also, painful sensations can go away on their own if the emotional or physical stimulus has been eliminated.

Characteristics of individual forms of angina pectoris:

• For the first time, angina pectoris is quite variable in its course, so it is not immediately possible to make an accurate diagnosis. This usually takes up to three months. During this period, the patient's condition is monitored, the development of the disease, which can go into a progressive or stable form.
• Stable angina is characterized by pain with a certain pattern. The severity of stable angina pectoris is determined by functional classes, the corresponding FC must be indicated in the final diagnosis.
• Progressive angina pectoris - the intensity of pain attacks increases rather quickly, while the patient's resistance to physical and emotional stress decreases. This form of angina pectoris is poorly controlled by nitroglycerin and, in severe cases, narcotic analgesics may be required.

Angina occurs spontaneously and is not associated with any physical or emotional stimuli. This form of angina is often determined at rest, at night or in the morning. This pathology is defined as spontaneous angina pectoris.

Sudden coronary death

The second clinical designation is primary cardiac arrest. Its formation is associated with electrical instability of the myocardium. Such a diagnosis is made only if there is no evidence for the definition of another specific form of coronary artery disease. For example, the heart may stop due to a myocardial infarction, and then the diagnosis is indicated as death from myocardial infarction.

A high risk of sudden coronary death is observed in those patients who have signs of narrowing of a large number of coronary vessels on coronary angiography. An unfavorable condition is the expansion of the left ventricle. Significantly increases the likelihood of sudden coronary death after a heart attack. Also, any myocardial ischemia, including without pronounced painful sensations, can be considered as a danger due to a sudden cessation of cardiac activity.

Postinfarction cardiosclerosis

In clinical practice, this disease is considered a complication of a previous myocardial infarction. To make such a diagnosis, at least 2 months are allotted. In some cases, postinfarction cardiosclerosis is considered as an independent disease, but for this, the presence of angina pectoris, heart failure, etc. should not be confirmed. In addition, signs of focal or diffuse cardiosclerosis should be present on the ECG.

In relatively mild cases, patients feel interruptions in the rhythm of the heart. The severe course of the disease is accompanied by shortness of breath, edema, heart pain, inability to endure the load, etc. The complexity of the pathology lies in the fact that there is a more or less noticeable progression of the process, which only for a while can be retained by well-chosen therapy.

Video: Types and forms of coronary heart disease

Diagnostics

Patients with coronary heart disease are dealt with by a cardiologist who, during the initial appointment, pays attention to clinical symptoms. With IHD, the following characteristic complaints are distinguished:

• Pain behind the sternum, which in most cases is associated with emotional and physical activity.
• Incorrect work of the heart, which is accompanied by weakness and arrhythmia.
• Swelling in the legs, indicating heart failure.
• Feeling short of breath.

The history of the disease is of great importance during the examination. This is when the doctor asks clarifying questions about the nature of the pain, its duration, etc. The amount of physical activity that the patient can withstand relatively calmly also matters. For a correct diagnosis, information must be obtained on the effectiveness of various pharmacological agents, including nitroglycerin. Additionally, risk factors are specified.

All patients with suspected coronary artery disease undergo electrocardiography. This indirect diagnostic method cannot accurately indicate how many cardiomyocytes have died, but it can be used to determine myocardial functions such as automatism and conduction capacity.

The following signs of myocardial infarction are clearly visible on the ECG:

• The appearance of a pathological Q wave, which in some leads is combined with a negative T wave.
• In acute myocardial infarction, the ST segment rises high and manifests itself in the form of a "sailboat" or "cat's back".
• With myocardial ischemia, ST segment depression is noted.
• If there is a scar in the myocardium on the ECG for two days or more, a negative T wave of weak severity and a pathological Q wave are determined.

An ECG is necessarily supplemented by an ultrasound of the heart. Using this modern method of research, it is possible to assess the state of the heart muscle in real time, how much the contractility of the heart has suffered from a heart attack, and whether there are abnormalities in the functioning of the valvular apparatus. If necessary, echocardiography is combined with dopplerography, which makes it possible to assess the possibilities of blood flow.

Laboratory research relevant for the diagnosis of myocardial infarction, because in the course of development pathological process different biochemical indicators. First of all, protein fractions are determined, which are normally found only inside the cell, and after the destruction of cardiomyocytes they enter the blood. For example, in the first 8 hours after a heart attack, the level of creatine kinase increases, and in the first day - myoglobin. Up to 10 days, troponins are determined, the amount of lactate dehydrogenase and aminotransferase also matters.

In violation of the structure of the myocardium, a nonspecific reaction is observed in the form of an increase in the concentration of AST and ALT, the erythrocyte sedimentation rate (ESR) and the appearance of neutrophilic leukocytosis.

In patients with coronary artery disease, the lipid profile must be examined. For this, indicators such as total cholesterol, triglycerides, high and low density lipoproteins, apolipoproteins and an atherogenic index are determined.

Functional trials in combination with ECG registration, it is possible to assess the capabilities of the heart muscle under the influence of physical exertion. For early diagnosis of the disease, this is extremely important, since not all patients at rest have clinical changes. A person can be stressed in a variety of ways. The most common is the exercise bike. It is also often used a treadmill, walking up the stairs, etc.

Additional instrumental studies:

• CT angiography (or angiography of the coronary vessels) is carried out in order to obtain x-ray images with vessels contrasting with a special substance. The resulting images show blockage of the arteries, their occlusion, and the degree of patency is also assessed.
• Monitoring according to the Holter method - consists in recording an ECG for a day or two, for which the patient carries a special device with him all the time. The study allows you to determine not pronounced and hidden changes in cardiac activity, when a standard ECG cannot fix changes due to the rare occurrence of an attack.
• Intraesophageal ECG - performed in cases where no changes are recorded on the standard ECG, but there are Clinical signs the presence of additional foci of excitation. To conduct a study, an active electrode is inserted into the esophagus, which studies the electrical activity of the atria and atrioventricular node.

IHD treatment

The tactics of treatment is based on the classification of coronary heart disease, since each clinical form is suitable for its own specific method of therapy. Despite this, there are general guidelines for managing patients with coronary artery disease, which are as follows:

• Moderate physical stress is important in stabilizing patients with coronary artery disease, since the higher the physical activity, the greater the need for oxygen, and due to impaired blood supply to the heart muscle, this only aggravates the course of the disease by provoking new attacks. If the patient is on the mend, then gradually physical activity increases.
• Diet food - should be as sparing as possible for the myocardium, therefore the amount of salt and the volume of water are reduced. When determining atherosclerosis, foods such as smoked meats, pickles, animal fats are excluded from the diet. High-calorie and fatty foods are also not recommended for use. If the patient is obese, then the issue of counting calories is especially carefully approached, since energy expenditure should be related to the energy coming from food.

Medical therapy

US cardiologists proposed a treatment regimen under the abbreviation "A-B-C". It is based on the use of drugs from three pharmacological groups: antiplatelet agents, beta-blockers, statins (considered hypocholesterolemic drugs). If a concomitant disease is determined in the form of hypertension, then drugs are added to treat this pathology.

• Antiplatelet agents - prevent erythrocytes and platelets from sticking together, as well as their further adhesion to the inner wall of the vessel. As a result, blood rheology improves, and the risk of developing blood clots decreases. Of the drugs in this group, acecardol, aspirin are most often used, and clopidogrel is also prescribed.
• Beta-blockers - according to the mechanism of action, stimulate adrenoreceptors in myocardial cells, which leads to a decrease in heart contractility. This, in turn, has a beneficial effect on the condition and performance of the body. Drugs from this group are contraindicated in certain pulmonary diseases. Today, metoprolol, carvedilol, bisoprolol are most often used.
• Statins and fibrates are anticholesterolemic drugs, as they help slow down the growth of existing atherosclerotic plaques and prevent the formation of new ones. To some extent, they can alleviate the severity of an attack of coronary artery disease. Of this group, lovastatin, simvastatin, rosuvastatin, atorvastatin are most often prescribed. Fibrates can increase the level of high-density lipoproteins, which have anti-atherogenic value, among which fenofibrate is the most famous.

Depending on the indications and comorbidity, the patient may be prescribed nitrates (they expand the venous bed and thereby relieve the load on the heart), anticoagulants (do not allow blood clots to form), diuretics (loop or thiazide). Antiarrhythmic agents in the form of amiodarone may also be prescribed for the treatment and prevention of rhythm disorders.

Video: What drugs are used to treat coronary heart disease (CHD)?

Natural lipid-lowering agents

In complex therapy, lipid-lowering agents such as aspirin and policosanol can be used. The latter name is a general term for long-chain alcohols that are made from vegetable waxes. Today, they are often found in various nutritional supplements.

In the process of application, policosanol does not have a negative effect on coagulation, while it helps to increase the concentration of high-density lipoproteins and reduce the fraction of “harmful” low-density lipoproteins. Additionally, the substance has an antiplatelet effect.

Endovascular coronary angioplasty

It is an alternative to open surgery. It is used in various forms of coronary artery disease, even in the case of progression of the pathology and in order to prevent complications. This method combines coronary angioplasty and endovascular technologies, often represented by transluminal and transluminal instrumentation.

To expand spasmodic vessels, due to which myocardial ischemia occurs, stenting is most often used, less often balloon angioplasty. All manipulations are performed under the control of coronary angiography and fluoroscopy. For the introduction of the required instrumentation, a large vessel is selected, mainly the femoral artery is preferred.

Video: Stenting of the coronary arteries

Surgery

In some circumstances, coronary heart disease is not amenable to medical treatment. Then the option of surgical intervention is considered, in particular, coronary artery bypass grafting. The purpose of this technique is to connect coronary vessels with the aorta by means of an autograft (represented mainly by the great saphenous vein).

The main indications for surgical intervention with IBS:

• multiple lesions of the coronary vessels;
• determination of stem stenosis in the region of the left coronary vessel;
• determination of ostial stenoses in the region of the right or left coronary vessel;
• stenosis of the anterior coronary vessel, which is not amenable to angioplasty.

Surgical treatment cannot be carried out in the case when the patient has multiple lesions of peripheral coronary vessels, located diffusely. Also, a contraindication is low myocardial contractility, the presence of heart failure in the stage of decompensation and a post-infarction state, which is not more than 4 months old.

Non-drug treatment

Conservative therapy, if necessary, can be supplemented by non-drug methods of exposure, which also help to improve the condition of the myocardium.

The main methods of treatment of non-drug direction:

• Hirudotherapy is known as leech therapy. In the saliva of these creatures there are components with an antiplatelet effect, as a result of which thrombosis is prevented. It is difficult to judge the effectiveness of the method, since it does not have approval from the field of evidence-based medicine.
• Shock wave therapy of the heart - for the implementation of the technique, low power of shock waves is used. Under their action, new vessels begin to form in the myocardium, which significantly improves blood supply to the tissues. This is exactly what is needed to reduce the ischemic zone. The non-invasive method is most often used in the absence of effectiveness from conservative and surgical treatment. According to some researchers, improvement in myocardial perfusion is observed in almost 60% of patients.
• Enhanced external counterpulsation - in terms of the method of conduction, it is similar to internal counterpulsation. Refers to non-surgical methods and is based on the work of special air cuffs that are worn on the legs. Due to the sharp pumping out of air from the cuffs during systole, the pressure in the vascular bed decreases, which means that the load on the heart is removed. At the same time, during the period of diastole, the bloodstream, on the contrary, is intensively filled with blood, which improves the condition of the myocardium. After a large study in the USA, the method was approved and is now widely used in clinics.

Forecast

The conclusion on the development of the disease largely depends on the severity of the clinic and the severity of structural changes in the myocardium. In most cases, a relatively unfavorable prognosis is given, since, regardless of the treatment, it is impossible to reverse the disease. The only thing is that therapy helps to improve the patient's well-being, make attacks less frequent, in some cases it is possible to significantly improve the quality of life. Without treatment, the disease progresses very quickly and is fatal.

Under the general name coronary heart disease (CHD, coronary disease) unite a group of diseases caused by oxygen starvation of tissues caused by insufficiency of coronary blood flow, absolute or relative. The root cause of myocardial blood supply disorders is atherosclerotic stenosis of the coronary arteries. Cardiac ischemia is considered as a cardiac form of arterial hypertension and atherosclerosis. Ischemic phenomena caused by the course of other diseases are not classified as manifestations of IHD.

Ischemic heart disease has many variants of the course and clinical manifestations, new data on the causes and mechanisms of the development of pathology appear every year. Therefore, there is no single classification of cardiac ischemia yet. In clinical practice, acute and chronic coronary artery disease are distinguished. Acute myocardial ischemia is divided into the following forms:

• Sudden coronary death;
• Painless myocardial ischemia:
• angina;

Chronic forms of coronary artery disease:

• Postinfarction cardiosclerosis;
• Atherosclerotic diffuse cardiosclerosis;
• Chronic aneurysm of the heart.

Sudden coronary death

In this form, the disease can be asymptomatic, the heart stops unexpectedly, in the absence of visible prerequisites for a fatal outcome. With immediate medical attention, successful resuscitation of the patient is possible. Many cases occur outside the hospital, mortality in this form of IHD approaches 100%.

Factors that increase the likelihood of sudden coronary death:

• Heart failure;
• Severe arterial hypertension;
• Strong psycho-emotional stress;
• Ischemia of the heart, aggravated by ventricular forms of arrhythmia;
• Postponed myocardial infarction;
• Chronic intoxication;
• Disorders of carbohydrate or fat metabolism.

Painless myocardial ischemia

The disease is asymptomatic for a long time and often leads to sudden death of the patient. In this case, ischemia leads to typical complications: arrhythmias and heart failure. Often, signs of painless ischemia are detected by chance, when contacted for other reasons. At risk are people with heavy physical labor, the elderly, those suffering from diabetes. The painless form of coronary artery disease is more common in people who abuse alcohol.

Sometimes the disease is manifested by sensations of vague discomfort in the chest, accompanied by a decrease in blood pressure. There may be heartburn or shortness of breath, sometimes weakness in the left arm.

Holter monitoring and/or stress ECG is required to confirm the diagnosis. During an exercise-induced attack, the ECG shows characteristic signs of ischemia. Treatment of painless ischemia is carried out according to the scheme typical for all forms of coronary artery disease. The prognosis varies depending on the severity of the identified lesion.

angina pectoris

Has a paroxysmal course. Angina attacks develop when the myocardium requires more oxygen than it receives at the moment. The patient has a feeling of suffocation, discomfort, compression or pain in the heart, the heart rhythm changes. The nature and intensity of anginal pain in angina attacks vary greatly. The pain radiates along the left side of the chest, into the arm, neck, jaw, under the shoulder blade. Less often, irradiation occurs to the right side or the epigastric region. Signs of coronary heart disease in men in most cases manifest themselves in the form of classic angina attacks.

An attack can be triggered by:

• Unusual or excessive physical activity;
• Strong excitement, emotional stress;
• Binge eating;
• The transition from warm to cold.

Attacks have a clearly defined beginning and end, disappear spontaneously after the load is removed or are stopped by vasodilators (nitroglycerin or validol).

There are several forms of angina pectoris, in particular, stable and unstable. With a stable course, the onset of an attack is relatively predictable, the same loads are accompanied by stereotypical reactions. If within 15 minutes the pain does not go away, despite the elimination of the provoking factor and / or the intake of nitroglycerin, irreversible changes begin in the myocardium, a heart attack develops.

The weakening of the effectiveness of the usual drugs indicates a possible transition of angina into unstable or progressive. Unstable also includes angina, which arose for the first time. In this case, the prognosis is unclear, signs of ischemia may disappear completely, the disease may become stable or lead to myocardial infarction. The most dangerous is progressive angina, in which attacks become more frequent, longer and more painful. This condition often precedes myocardial infarction. Patients with any form of angina pectoris should be observed by a cardiologist for timely detection of changes in health status and prevention of complications.

Strong physical or emotional stress, tachycardia attacks or a prolonged angina attack can lead to myocardial infarction. The increased demand of the myocardium stimulates an increased flow of blood into the coronary bed and, at the same time, damage to atherosclerotic plaques is possible. The damaged plaque completely or partially blocks the lumen of the vessel, tissue necrosis develops in the affected area. The degree of myocardial damage depends on the location and degree of blockage of the coronary vessels. The defeat of the small arteries of the coronary bed leads to the development of small foci of necrosis, with complete blockage of the lumen of one of the coronary arteries, a macrofocal, transmural or extensive myocardial infarction develops.

A possible myocardial infarction is indicated by severe sudden pain behind the sternum, accompanied by a fear of death. The pain radiates throughout the chest, the direction and area of ​​irradiation depend on the location and extent of myocardial damage. Among the atypical symptoms of a heart attack are abdominal pain, nausea, and vomiting. It is important to note that the signs of coronary disease in women and people with diabetes often differ from classic anginal pain. The clinical variant of the course may refer to one of the rare variants of the course, up to painless.

Suspicion of myocardial infarction is a direct indication for emergency hospitalization of the patient. Modern methods of treating coronary artery disease have significantly reduced the recovery time after a heart attack, but it is still impossible to completely restore myocardial function. In the postinfarction period, coronary heart disease becomes chronic. The patient is forced to take maintenance drugs for life and be observed by a doctor.

Chronic forms of coronary artery disease

Cardiosclerosis

Cardiosclerosis can be focal or diffuse.

The focal form is a connective tissue scar that replaces a necrotic area of ​​the heart muscle after a myocardial infarction. diffuse cardiosclerosis develops as a result of the gradual replacement of cardiomyocytes with connective tissue elements. Connective tissue is not capable of contractions, due to the increased load on unchanged areas of the myocardium, their hypertrophy occurs, accompanied by deformation of the valves. Focal cardiosclerosis is detected after the final scarring of the necrotic area of ​​the heart muscle, i.e. 3-4 months after myocardial infarction. Hypertrophy of areas of the heart walls not affected by a heart attack occurs, dangerous forms of arrhythmia and chronic heart failure develop.

Diffuse cardiosclerosis develops slowly, years may pass from the onset of pathological changes to the first clinical manifestations. Contribute to the development of cardiosclerosis inflammatory diseases myocardial infarction, physical inactivity, chronic intoxication, overeating, unbalanced nutrition.

Cardiosclerosis refers to irreversible pathologies, maintenance therapy does not eliminate arrhythmia and manifestations of CHF, but only alleviates the patient's condition.

heart aneurysm

Cardiac aneurysm is another variant of post-infarction chronic course of coronary artery disease. It is a saccular protrusion of a thinned area of ​​\u200b\u200bthe myocardium and belongs to pathologies that do not imply a favorable outcome without qualified help. Conservative methods of treating coronary heart disease with aneurysm are used to strengthen the myocardium and stabilize the patient's condition before surgery.

Causes of the disease

The main cause of most cases of coronary artery disease is atherosclerotic lesions of the arteries of the coronary bed. Atherosclerosis and arterial hypertension are the main background diseases for the development of IHD. Factors indirectly contributing to the development of this pathology include:

• Wrong nutrition. This category includes foods rich in fats and fast carbohydrates. Such food leads either to the direct formation of cholesterol plaques on the walls of blood vessels, or to profound metabolic disorders and obesity.
• Excess weight. In overweight people, the heart works in constant overload mode, obesity is one of the most common causes of many cardiopathologies. Therefore, all recommendations on how to treat cardiac ischemia necessarily contain a clause on the need to keep weight under control.
• Emotional overstrain. The release of adrenaline in stressful conditions prepares the body for the choice of “flight or fight”, the heart switches to a more intense mode of operation. Acute coronary heart disease often first manifests itself against the background of strong excitement. In a state of chronic stress, myocardial wear accelerates. In addition, the biochemistry of stress contributes to the formation of cholesterol deposits on the walls of blood vessels.
• chronic intoxication. Occasional use of alcohol, tobacco in any form or drugs leads to short-term violation heart function and of cardio-vascular system generally. with systematic use, the heart works in an abnormal mode almost constantly, which causes pathological changes in the vessels and myocardium.
• Endocrine diseases, in particular diabetes mellitus, dysfunction thyroid gland, tumors of the adrenal glands.
• Insufficient or excessive physical activity.

Additional risk factors elderly age, belonging to the male sex, insufficiency of certain microelements.

Symptoms

The classic manifestation of cardiac ischemia is an attack of angina pectoris with characteristic retrosternal pain, known as anginal. The pain is described as burning, pressing, stabbing, varying in intensity from vague discomfort to unbearable. Anginal pain radiates along the left side of the chest (rarely - on the right), into the left arm, neck, jaw. With a massive heart attack, pain spreads throughout the chest. The attack has a clearly defined beginning and end, passes when the influence of the provoking factor is removed or after taking vasodilator drugs. Anginal pain may be accompanied by:

• Dyspnea. It manifests itself as a reaction to oxygen starvation during each attack. As the disease progresses, shortness of breath can disturb the patient even at rest.
• Dizziness, loss of consciousness.
• Increased heart rate.
• Increased sweating. Sweat is usually cold and clammy.
• Nausea, less often - vomiting, which does not bring relief.

In severe attacks of angina pectoris and a developing heart attack, an additional sign of ischemia is an unreasonable fear of death, anxiety, anxiety bordering on panic. It should be noted that types of ischemia with a non-standard course may be accompanied by symptoms resembling clinical manifestations neurological, gastroenterological and other pathologies.

Diagnostics

The initial stage of diagnosis is always the analysis of the medical history, the patient's life and family history to determine the hereditary predisposition to the development of cardiopathology. During a physical examination, the doctor determines the presence of murmurs in the heart and lungs, an increase in the size of the heart.

For rate general condition organism and detection of probable metabolic disorders are carried out:

• General urine and blood tests;
• Blood chemistry;
• Examination for the presence of cardiospecific enzymes;
• Coagulogram.

Most informative diagnostic methods are methods of instrumental research, such as:

• ECG, stress ECG;
• 24-hour Holter monitoring;
• echocardiography;
• Coronary angiography;
• Multislice CT.

Diagnostic methods are selected individually, depending on the patient's condition, the proposed diagnosis, treatment tactics and the technical capabilities of the clinic.

Treatment

Treatment of coronary heart disease includes a whole range of activities. First of all, it is required to stabilize the patient's condition and prevent possible complications.

In the medical treatment of IHD, the following drugs are used:

• Anti-ischemic, in particular, calcium antagonists or beta-blockers;
• ACE inhibitors;
• Drugs that lower blood cholesterol levels;
• Antiplatelet agents, anticoagulants to improve blood flow.

Additionally, diuretics, antiarrhythmic drugs and vasodilators are prescribed. Some medications for coronary artery disease the patient will have to take for life.

With obviously ineffective conservative treatment, patients are shown surgical treatment of ischemia. To restore blood flow in the affected myocardium are performed.

Under IHD (in deciphering the definition - ischemic heart disease) a complex of diseases is grouped. They are characterized by unstable blood circulation in the arteries that supply the myocardium.

Ischemia - insufficient blood supply - is caused by narrowing of the coronary vessels. Pathogenesis is formed under the influence of external and internal factors.

IHD leads to death and disability of people of working age around the world. WHO experts have calculated that the disease is becoming the cause of the annual death of more than 7 million people. By 2020, mortality could double. It finds the greatest distribution among men 40 — 62 years.

The combination of the processes discussed below increases the risk of morbidity.

Main causative factors:

• Atherosclerosis. A chronic disease that affects the arteries that go to the heart muscle. The vascular walls thicken and lose their elasticity. Plaques formed by a mixture of fats and calcium narrow the lumen, the deterioration of the blood supply to the heart progresses.
• Spasm of the coronary vessels. The disease is caused or formed without it (under the influence of external negative factors, such as stress). The spasm changes the activity of the arteries.
• Hypertonic disease- The heart has to fight high pressure in the aorta, which disrupts its circulation and causes angina and heart attack.
• Thrombosis/thromboembolism. In the artery (coronary), as a result of the collapse of an atherosclerotic plaque, a thrombus is formed. There is a high risk of blockage of the vessel by a thrombus, which formed in another part of the circulatory system and got here with the bloodstream.
• or .

Atherosclerosis is the main cause of coronary artery disease.

The risk factors are considered to be:

• hereditary factor - the disease is transmitted from parents to children;
• steadily elevated "bad" cholesterol, causing the accumulation of HDL - high density lipoprotein;
• smoking;
• obesity of any degree, disorders of fat metabolism;
• arterial hypertension - a high level of pressure;
• diabetes (metabolic syndrome) - a disease caused by a violation of the production of the pancreatic hormone - insulin, which leads to malfunctions of carbohydrate metabolism;
• lifestyle deprived of physical activity;
• frequent psycho-emotional disorders, character and personality traits;
• adherence to an unhealthy fatty diet;
• age - risks increase after 40 years;
• gender - men suffer from coronary artery disease more often than women.

Classification: forms of coronary heart disease

IHD is divided into several forms. It is customary to distinguish between acute and chronic conditions.

Cardiologists manipulate such a concept as acute coronary syndrome. It combines some forms of coronary artery disease: myocardial infarction, angina pectoris, etc. Sometimes this includes sudden coronary death.

What is dangerous, complications, consequences

Ischemic heart disease indicates the presence of changes in the myocardium, which leads to the formation of progressive insufficiency. Contractility weakens, the heart does not provide the body with the required amount of blood. people with coronary artery disease get tired quickly and experience constant weakness. Lack of treatment increases the risk of death.

Clinic of the disease

Manifestations can emerge in a complex or separately, depending on the form of the disease. There is a clear relationship between development pain localized in the region of the heart, and physical activity. There is a stereotype of their occurrence - after a plentiful meal, under adverse weather conditions.

Description of pain complaints:

• character - pressing or squeezing, the patient feels a lack of air and a feeling of increasing heaviness in the chest;
• localization - in the precordial zone (along the left edge of the sternum);
• negative sensations can spread along the left shoulder, arm, shoulder blades or in both hands, in the left pre-scapular zone, in the cervical region, jaw;
• pain attacks last no more than ten minutes, after taking nitrates they subside within five minutes.

We talked in more detail about, including differences in signs in men and women and risk groups, in a separate article.

If the patient does not seek treatment and the disease proceeds for a long time, the picture is supplemented by the development of swelling in the legs. The patient suffers from severe shortness of breath, which forces him to take a sitting position.

A specialist who can help with the development of all the conditions considered is a cardiologist. Timely medical attention can save lives.

Diagnostic methods

Diagnosis of IHD is based on the following examinations:

To clarify the diagnosis and exclude the development of other diseases, a number of additional studies are being implemented.

According to the plan, the patient receives a complex of stress tests (physical, radioisotope, pharmacological), undergoes X-ray contrast examinations, computed tomography of the heart, electrophysiological examination, dopplerography.

How and what to treat

The tactics of complex therapy for coronary artery disease is developed based on the patient's condition and an accurate diagnosis.

Therapy without medication

Principles of IHD treatment:

• daily cardio training in dynamics (swimming, walking, gymnastics), the degree and duration of the load is determined by the cardiologist;
• emotional peace;
• the formation of a healthy diet (a ban on salty, fatty).

Pharmacological support

The following drugs may be included in the treatment plan:

Anti-ischemic- reduce myocardial oxygen demand:

• Calcium antagonists are effective in the presence of contraindications to beta-blockers and are used with low effectiveness of therapy with their participation.
• beta-blockers - relieve pain, improve rhythm, dilate blood vessels.
• nitrates - stop angina attacks.
• Antiplatelet agents– pharmacological preparations that reduce blood clotting.
• ACE inhibitors- drugs of complex action to reduce pressure.
• Hypocholesterolemic medicines (fibrators, statins) - eliminate bad cholesterol.

As additional support and according to indications, the therapy plan may include:

• diuretics- diuretics to relieve swelling in patients with coronary artery disease.
• antiarrhythmics- maintain a healthy rhythm.

Learn more about in a separate post.

Operations

Surgical regulation of myocardial blood supply. A new vascular bed is brought to the site of ischemia. The intervention is implemented in case of multiple vascular lesions, with low efficiency of pharmacotherapy and in a number of concomitant diseases.

Coronary angioplasty. Wherein surgical treatment A special stent is inserted into the affected vessel, which keeps the lumen normal. The blood flow of the heart is restored.

Forecast and prevention

Cardiologists point out that IHD has a poor prognosis. If the patient complies with all prescriptions, the course of the disease becomes not so severe, but it does not disappear completely. Effective preventive measures include healthy lifestyle life (proper nutrition, absence of bad habits, physical activity).

All persons who are predisposed to the development of the disease are recommended to visit a cardiologist regularly. This will help maintain a full quality of life and improve the prognosis.

A useful video about what kind of diagnosis it is - "coronary heart disease", all the details about the causes, symptoms and treatment of coronary artery disease are given: