Coronary heart disease

Risk factors

The reasons

Types of coronary heart disease

Diagnostics

Differential diagnostics

Treatment of Ischemic Heart Disease

Coronary heart disease (CHD) is a disease caused by a mismatch between the oxygen demand of the heart muscle and its delivery, leading to impaired heart function. In Russia and many European countries, this pathology is one of the main causes of premature mortality, and this indicator is growing from year to year.

Risk factors

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  • male gender (young and middle-aged men suffer from ischemic heart disease more often, the incidence becomes the same with age)
  • age over 65, although now ischemic heart disease is “younger”
  • smoking
  • alcohol abuse
  • hypodynamia (low physical activity)
  • heredity
  • dyslipidemia – a violation of the lipid composition of the blood, which increases the content of “bad” cholesterol – low density lipoprotein (LDL) and decreases the content of high density lipoprotein (HDL)  
  • diabetes
  • arterial hypertension 
  • increased heart rate
  • violations in the blood clotting system, such as increased blood clotting
  • overweight (the most dangerous is abdominal obesity, it can be indicated by waist circumference> 88 cm in women and> 102 cm in men). 
  • severe or prolonged stress
  • combined oral contraceptive use

The reasons

  • atherosclerosis of the coronary arteries (up to 95% of cases) 
  • spasm of unchanged coronary arteries (rare)

Types of coronary heart disease

  • Sudden coronary death (primary cardiac arrest)
  • Angina pectoris
    • exertional angina
    • spontaneous angina pectoris
  • Painless myocardial ischemia
  • Cardiac X syndrome
  • Myocardial infarction
  • Postinfarction cardiosclerosis
  • Heart rhythm disorders
  • Heart failure

Angina pectoris in IHD and its symptoms

It should focus on angina, because This is the most common manifestation of CHD.

Angina is manifested by the following symptoms:

  • pain behind the sternum of an oppressive or constricting nature,
  • pain may radiate to the left arm, shoulder, lower jaw,
  • It is stopped at rest or taking nitroglycerin. 

Such a clinic may occur in response to the following factors: 

  • occurs more often after exercise,
  • with increasing blood pressure 
  • in the cold
  • after a heavy meal, 
  • with a strong emotional stress. 

The duration of the attack, as a rule, a few minutes.

  • With stable angina, pressing pain occurs with a certain physical exertion (for example, the patient passes 200 m).
  • Progressive angina is diagnosed if the load tolerance decreases with time (i.e. the patient can bear less and less stress without an attack ). Progressive and newly emerged angina are unstable and require immediate medical attention, and sometimes hospitalization.
  • When rest angina pectoris attacks occur more often at night, during the early morning hours, they can be accompanied by the fear of death, a feeling of lack of air.

Diagnostics

For the diagnosis of coronary heart disease, patient complaints are primarily important, as CHD is primarily a clinical diagnosis. To confirm it , laboratory and instrumental research methods are used.  

Laboratory:

  • complete blood count (possible leukocytosis; decrease in hemoglobin with non-vascular causes of pain) 
  • biochemical blood test (elevated cholesterol and LDL, low HDL, increase in glucose ). 

Instrumental methods

Invasive

  • coronary angiography (x-ray examination of vessels with a contrast agent, often combined with a surgical method for the treatment of coronary artery disease – stenting),
  • intravascular ultrasound (visualization of atherosclerotic plaques in the coronary vessels, rarely used due to the low availability of technology),
  • transesophageal electrostimulation (for the diagnosis of latent coronary insufficiency when it is impossible to use non-invasive examination methods).

These procedures are carried out only in the hospital. 

Non-invasive

  • ECG (ischemic changes)
  • 24 -hour Holter ECG monitoring 
  • ECG with physical activity (bicycle ergometry or treadmill test on a treadmill)
  • ECHO-KG (echocardiography) at rest 
  • ECHO-KG with pharmacological or physical activity
  • radionuclide methods (the substance is distributed in myocardial tissue and clearly visualizes areas with insufficient blood flow) 
  • MRI of the heart (with visualization problems using ECHO-KG). 

Differential diagnostics

Diagnosis of coronary artery disease is quite easy to make with a typical course of the disease, since it has characteristic signs. However, it is worth noting that many other diseases can copy the symptoms of myocardial ischemia. Difdiagnosis requires a list of diseases of the gastrointestinal tract, broncho-pulmonary, cardiovascular, nervous and musculoskeletal systems. In addition, there may be similar symptoms in a number of mental illnesses. Only a qualified specialist can understand all this. 

Treatment of Ischemic Heart Disease

The main principle of treatment of coronary heart disease is the restoration of blood flow to the damaged areas of the myocardium and the prevention of complications.

There are 2 main directions in the treatment of IHD:

1. Stopping an attack of stenocardia:

  • you must stop exercising
  • provide fresh air
  • take nitroglycerin under the tongue, or use nitrate as a spray.

2. Basic therapy.

Drug free drugs

To give up smoking

Dieting. 

  • decrease in the consumption of animal fats up to 30% of the total energy value of food,
  • decrease in consumption of saturated fats up to 30% of the total amount of fats,
  • cholesterol consumption not more than 300 mg / day
  • increased consumption of fresh fruits, plant foods, cereals,
  • limiting the consumption of total calories when overweight,
  • reduction of salt and alcohol intake with high blood pressure.

Increased physical activity. 
Recommendations for increasing physical activity should be given strictly individually, depending on the diagnosis. The following exercises are possible : 

  • fast walk,
  • jogging,
  • swimming,
  • cycling and skiing
  • tennis,
  • volleyball,
  • dancing with aerobic exercise.

In this case, the heart rate should be no more than 60-70% of the maximum for a given age.

The duration of exercise should be 30-40 minutes:

  • 5-10 min warm up
  • 20-30 min aerobic phase
  • 5-10 min. Final phase.

Regularity 4-5 p / week (for longer classes – 2-3 p / week).

With a body mass index of more than 25 kg / m2, it is necessary to reduce body mass through diet and regular exercise. This leads to a decrease in blood pressure, a decrease in blood cholesterol concentration.

Drug therapy

With elevated blood pressure, antihypertensive therapy is prescribed in the absence of the effect of non-drug treatment (see arterial hypertension ). Blood pressure less than 140/90 mm Hg is considered optimal. 

Treatment of diabetes is the proper selection of glucose-lowering therapy and careful monitoring of blood glucose. 

Treatment of atherosclerosis is an essential component in the treatment of coronary artery disease. The most common for this purpose are statins:  

  • Rosuvastatin,
  • atorvastatin,
  • simvastatin.

During the reception of these drugs, it is necessary to monitor the lipid spectrum and liver indices ( ALT , AST , CK, LDH) 1 time in 3 months. 

Fibrates are less commonly used, such as fenofibrate.

Antiplatelet therapy:

  • acetylsalicylic acid (it is better to use not the usual aspirin, but more modern drugs, such as Cardiomagnyl or Thromboc-Ass, since they are less aggressive in affecting the gastric mucosa)
  • in some cases clopidogrel is indicated.

Beta-blockers reduce myocardial oxygen demand. Currently, the use of selective drugs is preferable:

  • bisoprolol,
  • metoprolol,
  • nebivolol
  • carvedilol.

Calcium antagonists:

  • amlodipine,
  • nitrendipine and others

Prolonged nitrates (it should be noted that when taking this group of drugs, a frequent complication is headache, it is also possible a pronounced decrease in blood pressure.)

  • isosorbide dinitrate,
  • isosorbide mononitrate.

Other anti-ischemic drugs:

  • trimetazidine,
  • ranolazine
  • ivabradine.

Surgery

A certain role today is played by the surgical treatment of coronary heart disease. For this, the methods of myocardial revascularization (restoration of blood flow) are used. These include:

  • coronary artery bypass surgery is a complicated operation on the heart vessels in order to bypass the site of constriction with vascular prostheses.
  • percutaneous intervention – stenting (restoration of the vessel lumen using staging or carcass inside the vessel). 

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