Diagnosis and treatment of chronic ischemic heart disease Diagnosis of chronic ischemic heart disease (ch1). Ischemic heart disease Stenting ICD code

It is characterized by attacks of sudden pain in the retrosternal region. In most cases, the disease is caused by atherosclerosis of the coronary arteries and the development of myocardial blood supply deficiency, the deterioration of which occurs with significant physical or emotional stress.

Treatment of the disease in the form of monolaser therapy is carried out in the non-attack period; during the period acute manifestations treatment is carried out in combination with medications.

Laser therapy for coronary heart disease is aimed at reducing psycho-emotional excitability, restoring the balance of autonomic regulation, increasing the activity of the erythrocyte component of the blood, eliminating deficient coronary blood supply with the subsequent elimination of metabolic disorders of the myocardium, normalizing the blood lipid spectrum with a decrease in the level of atherogenic lipids. In addition, during pharmacolaser therapy, the effect of laser radiation on the body leads to a decrease in side effects. drug therapy, in particular associated with an imbalance of lipoproteins when taking b-blockers and increases sensitivity to the drugs used as a result of restoring the structural and functional activity of the receptor apparatus of the cell.

The tactics of laser therapy includes zones of mandatory impact and zones of secondary choice, which include the projection zone of the aortic arch and zones of the final choice, connected after 3-4 procedures, positioned in the projection of the heart.

Rice. 86. Projection zones of the heart area. Symbols: pos. "1" - projection of the left atrium, pos. "2" - projection of the left ventricle.

Irradiation of the heart preferably using pulsed infrared lasers. The irradiation mode is performed with pulsed power values ​​in the range of 6-8 W and a frequency of 1500 Hz (corresponding to myocardial relaxation due to a decrease in its sympathetic dependence), an exposure of 2-3 minutes for each field. The number of procedures in the course of treatment is at least 10.

With the relief of the main manifestations of the disease, the prescription is connected to the impact on the reflex zones: the area of ​​​​segmental innervation at the level of Th1-Th7, receptor zones in the projection of the inner surface of the shoulder and forearm, the palmar surface of the hand, the sternum area.

Rice. 87. Projection zone of impact on the area of ​​segmental innervation Th1-Th7.

Modes of laser impact on zones of additional impact

Stable angina pectoris

Stable exertional angina: Brief description

stable angina pectoris voltage- one of the main manifestations of coronary artery disease. The main and most typical manifestation angina pectoris - retrosternal pain that occurs during physical exertion, emotional stress, when going out into the cold, walking against the wind, at rest after a heavy meal.

Pathogenesis

As a result of a discrepancy (imbalance) between myocardial oxygen demand and its delivery through the coronary arteries due to atherosclerotic narrowing of the lumen of the coronary arteries, there are: Myocardial ischemia (clinically manifested by chest pain). Violations of the contractile function of the corresponding section of the heart muscle. Changes in biochemical and electrical processes in the heart muscle. In the absence of a sufficient amount of oxygen, cells switch to an anaerobic type of oxidation: glucose breaks down to lactate, intracellular pH decreases, and the energy reserve in cardiomyocytes is depleted. The subendocardial layers are affected first. The function of cardiomyocyte membranes is disrupted, which leads to a decrease in the intracellular concentration of potassium ions and an increase in the intracellular concentration of sodium ions. Depending on the duration of myocardial ischemia, the changes may be reversible or irreversible (myocardial necrosis, i.e., infarction). Sequences pathological changes with myocardial ischemia: violation of myocardial relaxation (impaired diastolic function) - violation of myocardial contraction (impaired systolic function) - ECG changes - pain syndrome.

Classification

Canadian Cardiovascular Society (1976). Class I - "regular" exercise stress does not cause angina. Pain does not occur when walking or climbing stairs. Seizures appear with strong, rapid or prolonged stress at work. Class II - "slight limitation of usual activity." Pain occurs when walking or climbing stairs quickly, walking uphill, walking or climbing stairs after eating, in cold, against the wind, with emotional stress, or within a few hours after waking up. Walking more than 100-200 m on level ground or climbing more than 1 flight of stairs at a normal pace and under normal conditions. Class III - "significant limitation of usual physical activity." Walking on level ground or climbing 1 flight of stairs at a normal pace in normal conditions provokes an angina attack. Class IV - "the impossibility of any physical activity without discomfort." Seizures may occur at rest

Stable exertional angina: Signs, Symptoms

CLINICAL MANIFESTATIONS

Complaints. Characteristics of the pain syndrome. Localization of pain - retrosternal. The conditions for the occurrence of pain are physical exertion, strong emotions, a plentiful meal, cold, walking against the wind, smoking. Young people often have the so-called phenomenon of "passing through pain" (the phenomenon of "warm-up") - a decrease or disappearance of pain with an increase or maintenance of the load (due to the opening of vascular collaterals). The duration of pain - from 1 to 15 minutes, has an increasing character ("crescendo"). If pain persists for more than 15 minutes, MI should be suspected. Conditions for cessation of pain - cessation of physical activity, taking nitroglycerin. The nature of pain in angina pectoris (compressive, pressing, arching, etc.), as well as the fear of death, are very subjective and do not have serious diagnostic value, since they largely depend on the patient's physical and intellectual perception. Irradiation of pain - both in the left and in the right parts of the chest and neck. Classical irradiation - to the left hand, lower jaw.

Associated symptoms- nausea, vomiting, increased sweating, fatigue, shortness of breath, increased heart rate, increased (sometimes decreased) blood pressure.

Angina equivalents: shortness of breath (due to impaired diastolic relaxation) and severe fatigue during exercise (due to a decrease in cardiac output in violation of systolic myocardial function with insufficient supply of skeletal muscles with oxygen). Symptoms in any case should decrease when the exposure to the provoking factor (exercise, hypothermia, smoking) stops or nitroglycerin is taken.

physical data. With an attack of angina pectoris - pallor of the skin, immobility (patients "freeze" in one position, since any movement increases pain), sweating, tachycardia (rarely bradycardia), increased blood pressure (less often its decrease). Extrasystoles, "gallop rhythm" can be heard. systolic murmur arising from mitral valve insufficiency as a result of dysfunction of the papillary muscles. An ECG recorded during an angina attack can detect changes in the terminal part of the ventricular complex (T wave and ST segment), as well as heart rhythm disturbances.

Stable exertional angina: Diagnosis

Laboratory data

- auxiliary value; allow to determine only the presence of dyslipidemia, to identify concomitant diseases and a number of risk factors (DM), or to exclude other causes of pain syndrome ( inflammatory diseases, blood diseases, thyroid diseases).

instrumental data

ECG during an angina attack: repolarization disturbances in the form of a change in the T waves and a shift in the ST segment up (subendocardial ischemia) or down from the isoline (transmural ischemia) or heart rhythm disturbances.

24-hour ECG monitoring allows you to identify the presence of painful and painless episodes of myocardial ischemia in the usual conditions for patients, as well as possible violations heart rate throughout the day.

Bicycle ergometry or treadmill (stress test with simultaneous recording of ECG and blood pressure). Sensitivity - 50-80%, specificity - 80-95%. The criterion for a positive exercise test during bicycle ergometry is ECG changes in the form of a horizontal depression of the ST segment of more than 1 mm lasting more than 0.08 s. In addition, stress tests can reveal signs associated with an unfavorable prognosis for patients with exertional angina: typical pain syndrome. ST segment depression greater than 2 mm. persistence of ST segment depression for more than 6 minutes after the termination of the load. the appearance of ST segment depression with a heart rate (HR) of less than 120 per minute. presence of ST depression in several leads, ST elevation in all leads except aVR. lack of rise in blood pressure or its decrease in response to physical activity. the occurrence of cardiac arrhythmias (especially ventricular tachycardia).

Echocardiography at rest allows you to determine the contractility of the myocardium and conduct differential diagnosis pain syndrome (heart defects, pulmonary hypertension, cardiomyopathy, pericarditis, mitral valve prolapse, left ventricular hypertrophy in arterial hypertension).

Stress - Echocardiography (Echocardiography - assessment of the mobility of the segments of the left ventricle with an increase in heart rate as a result of the administration of dobutamine, transesophageal pacemaker or under the influence of physical activity) is a more accurate method for detecting coronary artery insufficiency. Changes in local myocardial contractility precede other manifestations of ischemia ( ECG changes pain syndrome). The sensitivity of the method is 65-90%, the specificity is 90-95%. Unlike bicycle ergometry, stress echocardiography reveals insufficiency of the coronary arteries in case of damage to one vessel. Indications for stress - echocardiography are: . atypical angina pectoris tension (the presence of equivalents of angina pectoris or a fuzzy description of the pain syndrome by the patient). difficulty or impossibility of performing stress tests. uninformativeness of bicycle ergometry in a typical clinic of angina pectoris. no changes in the ECG during exercise tests due to blockade of the legs of the His bundle, signs of left ventricular hypertrophy, signs of Wolff-Parkinson-White syndrome in a typical clinic of angina pectoris. positive stress test on bicycle ergometry in young women (because the probability of coronary artery disease is low).

Coronary angiography is the "gold standard" in the diagnosis of coronary heart disease, since it allows you to identify the presence, location and degree of narrowing of the coronary arteries. Indications (recommendations of the European Society of Cardiology; 1997): . angina pectoris voltages above III functional class in the absence of effect drug therapy. angina pectoris voltage I-II functional class after MI. angina pectoris tension with blockade of the legs of the His bundle in combination with signs of ischemia according to myocardial scintigraphy. severe ventricular arrhythmias. stable angina pectoris in patients undergoing vascular surgery (aorta, femoral, carotid arteries) . myocardial revascularization (balloon dilatation, coronary artery bypass grafting). clarification of the diagnosis for clinical or professional (for example, in pilots) reasons.

Myocardial scintigraphy is a method of imaging the myocardium, which allows to identify areas of ischemia. The method is very informative when it is impossible to assess the ECG due to blockade of the legs of the His bundle.

Diagnostics

Typically, stable exertional angina is diagnosed based on a detailed history taking, a detailed physical examination of the patient, a resting ECG recording, and subsequent critical analysis of the findings. It is believed that these types of examinations (history, examination, auscultation, ECG) are sufficient to diagnose angina pectoris with its classic manifestation in 75% of cases. In case of doubts about the diagnosis, 24-hour ECG monitoring, stress tests (bicycle ergometry, stress - EchoCG) are consistently performed, if appropriate conditions are present, myocardial scintigraphy. At the final stage of diagnosis, coronary angiography is necessary.

Differential Diagnosis

It should be borne in mind that chest pain syndrome can be a manifestation of a number of diseases. It should not be forgotten that there can be several causes of chest pain at the same time. Diseases of the SSS. THEM. angina pectoris. Other reasons. possibly of ischemic origin: aortic stenosis, aortic valve insufficiency, hypertrophic cardiomyopathy, arterial hypertension, pulmonary hypertension, severe anemia. non-ischemic: aortic dissection, pericarditis, mitral valve prolapse. Diseases of the gastrointestinal tract. Diseases of the esophagus - spasm of the esophagus, esophageal reflux, rupture of the esophagus. Diseases of the stomach - peptic ulcer. Diseases of the chest wall and spine. Syndrome of the anterior chest wall. Anterior scalene syndrome. Costal chondritis (Tietze's syndrome). Rib damage. Shingles. Lung diseases. Pneumothorax. Pneumonia involving the pleura. PE with or without pulmonary infarction. Diseases of the pleura.

Stable angina pectoris: Treatment methods

Treatment

The goals are to improve the prognosis (prevention of MI and sudden cardiac death) and to reduce the severity (elimination) of the symptoms of the disease. Non-drug, drug (drug) and surgical methods treatment.

Not drug treatment- impact on CHD risk factors: dietary measures to reduce dyslipidemia and reduce body weight, smoking cessation, sufficient physical activity in the absence of contraindications. It is also necessary to normalize the level of blood pressure and correct carbohydrate metabolism disorders.

Drug therapy - three main groups of drugs are used: nitrates, b - adrenoblockers and blockers of slow calcium channels. Additionally, antiplatelet agents are prescribed.

Nitrates. With the introduction of nitrates, systemic venodilation occurs, leading to a decrease in blood flow to the heart (decrease in preload), a decrease in pressure in the chambers of the heart and a decrease in myocardial tension. Nitrates also cause a decrease in blood pressure, reduce resistance to blood flow and afterload. In addition, the expansion of large coronary arteries and an increase in collateral blood flow are important. This group of drugs is divided into short-acting nitrates (nitroglycerin) and long-acting nitrates (isosorbide dinitrate and isosorbide mononitrate).

To stop an attack of angina pectoris, nitroglycerin is used (tablet forms sublingually at a dose of 0.3-0.6 mg and aerosol forms - spray - used at a dose of 0.4 mg also sublingually). Short-acting nitrates relieve pain in 1-5 minutes. Repeated doses of nitroglycerin for the relief of an angina attack can be used at 5-minute intervals. Nitroglycerin in tablets for sublingual use loses its activity after 2 months from the moment the tube is opened due to the volatility of nitroglycerin, so regular replacement of the drug is necessary.

Long-acting nitrates (isosorbide dinitrate and isosorbide mononitrate) are used to prevent angina attacks that occur more often than 1 r / week. Isosorbide dinitrate at a dose of 10-20 mg 2-4 r / day (sometimes up to 6) 30-40 minutes before the intended physical activity. Retard forms of isosorbide dinitrate - at a dose of 40-120 mg 1-2 r / day before the expected physical activity. Isosorbide mononitrate at a dose of 10-40 mg 2-4 r / day, and retard forms - at a dose of 40-120 mg 1-2 r / day also 30-40 minutes before the intended physical activity.

Tolerance to nitrates (loss of sensitivity, addiction). Regular daily use of nitrates for 1-2 weeks or more can lead to a decrease or disappearance of the antianginal effect. The reason is a decrease in the formation of nitric oxide, an acceleration of its inactivation due to an increase in the activity of phosphodiesterases and an increase in the formation of endothelin-1, which has a vasoconstrictive effect. Prevention - asymmetric (eccentric) administration of nitrates (for example, 8 am and 3 pm for isosorbide dinitrate or only 8 am for isosorbide mononitrate). Thus, a nitrate-free period of more than 6-8 hours is provided to restore the sensitivity of the SMC of the vascular wall to the action of nitrates. As a rule, a nitrate-free period is recommended to patients for a period of minimal physical activity and a minimum number of pain attacks (in each case individually). Of the other methods of preventing tolerance to nitrates, the appointment of donators of sulfhydryl groups (acetylcysteine, methionine) is used, ACE inhibitors(captopril, etc.), angiotensin II receptor blockers, diuretics, hydralazine, however, the frequency of emergence of tolerance to nitrates against the background of their use decreases slightly.

molsidomine- close in action to nitrates (nitro-containing vasodilator). After absorption, molsidomine is converted to active substance, which is converted to nitric oxide, which ultimately leads to relaxation of vascular smooth muscles. Molsidomin is used at a dose of 2-4 mg 2-3 r / day or 8 mg 1-2 r / day (prolonged form).

b - Adrenoblockers. The antianginal effect is due to a decrease in myocardial oxygen demand due to a decrease in heart rate and a decrease in myocardial contractility. Used to treat angina pectoris:

Non-selective b - blockers (act on b1 - and b2 - adrenergic receptors) - for the treatment of angina pectoris, propranolol is used at a dose of 10-40 mg 4 r / day, nadolol at a dose of 20-160 mg 1 r / day;

Cardioselective b - adrenergic blockers (act mainly on b1 - adrenergic receptors of the heart) - atenolol at a dose of 25-200 mg / day, metoprolol 25-200 mg / day (in 2 doses), betaxolol (10-20 mg / day), bisoprolol (5 - 20 mg / day).

Recently, they began to use b - adrenergic blockers, causing expansion peripheral vessels, such as carvedilol.

Blockers of slow calcium channels. The antianginal effect consists in moderate vasodilation (including coronary arteries), a decrease in myocardial oxygen demand (in representatives of the verapamil and diltiazem subgroups). Apply: verapamil - 80-120 mg 2-3 r / day, diltiazem - 30-90 mg 2-3 r / day.

Prevention of MI and sudden cardiac death

Clinical studies have shown that the use of acetylsalicylic acid at a dose of 75-325 mg / day significantly reduces the risk of developing MI and sudden cardiac death. Patients with angina pectoris should be prescribed acetylsalicylic acid in the absence of contraindications - peptic ulcer, liver disease, increased bleeding, drug intolerance.

A decrease in the concentration of total cholesterol and LDL cholesterol with the help of lipid-lowering agents (simvastatin, pravastatin) also positively affects the prognosis of patients with stable angina pectoris. Currently, the optimal levels are considered for total cholesterol no more than 5 mmol / l (190 mg%), for LDL cholesterol no more than 3 mmol / l (115 mg%).

Surgery

When determining the tactics of surgical treatment of stable angina pectoris, it is necessary to take into account a number of factors: the number of affected coronary arteries, the ejection fraction of the left ventricle, the presence of concomitant diabetes. So, with one - two-vessel lesion with a normal left ventricular ejection fraction, myocardial revascularization is usually started with percutaneous transluminal coronary angioplasty and stenting. In the presence of two- to three-vessel disease and a decrease in the left ventricular ejection fraction of less than 45% or the presence of concomitant diabetes, it is more appropriate to perform coronary artery bypass grafting (see also Coronary artery atherosclerosis).

Percutaneous angioplasty (balloon dilatation) is the expansion of a section of the coronary artery narrowed by the atherosclerotic process with a miniature balloon under high pressure with visual control during angiography. The success of the procedure is achieved in 95% of cases. During angioplasty, complications are possible: mortality is 0.2% with single-vessel disease and 0.5% with multi-vessel disease, MI occurs in 1% of cases, the need for coronary artery bypass grafting appears in 1% of cases; . late complications include restenosis (in 35-40% of patients within 6 months after dilatation), as well as the appearance of angina pectoris (in 25% of patients within 6-12 months).

In parallel with the expansion of the lumen of the coronary artery, stenting has recently been used - implantation of stents (the thinnest wire frames that prevent restenosis) at the site of narrowing.

Coronary artery bypass grafting is the creation of an anastomosis between the aorta (or internal thoracic artery) and the coronary artery below (distal to) the site of narrowing to restore effective blood supply to the myocardium. As a transplant, a portion of the saphenous vein of the thigh, the left and right internal mammary arteries, the right gastroepiploic artery, and the inferior epigastric artery are used. Indications for coronary artery bypass grafting (recommendations of the European Society of Cardiology; 1997) . The ejection fraction of the left ventricle is less than 30%. Damage to the trunk of the left coronary artery. The only unaffected coronary artery. Left ventricular dysfunction in combination with a three-vessel lesion, especially with damage to the anterior interventricular branch of the left coronary artery in the proximal section. When performing coronary bypass surgery, complications are also possible - MI in 4-5% of cases (up to 10%). Mortality is 1% for single-vessel disease and 4-5% for multivessel disease. Late complications of coronary artery bypass grafting include restenosis (when using venous grafts in 10-20% of cases during the first year and 2% every year for 5-7 years). With arterial grafts, shunts remain open in 90% of patients for 10 years. Within 3 years angina pectoris recurs in 25% of patients.

Forecast

stable angina pectoris with adequate therapy and monitoring of patients is relatively favorable: mortality is 2-3% per year, fatal MI develops in 2-3% of patients. A less favorable prognosis is for patients with a decrease in the left ventricular ejection fraction, a high functional class of stable exertional angina, elderly patients, patients with multivessel coronary artery disease, stenosis of the main trunk of the left coronary artery, proximal stenosis of the anterior interventricular branch of the left coronary artery.

Clinical protocol for the diagnosis and treatment of diseases "IHD stable angina pectoris"

I. INTRODUCTION:

1. Name: IHD stable exertional angina

2. Protocol code:

3. Codes according to MKB-10:

4. Abbreviations used in the protocol:

AH - arterial hypertension

AA - antianginal (therapy)

BP - blood pressure

CABG - coronary artery bypass grafting

ALT - alanine aminotransferase

AO - abdominal obesity

ACT - aspartate aminotransferase

CCB - calcium channel blockers

GPs - General Practitioners

VPN - upper limit norm

WPW - Wolff-Parkinson-White Syndrome

HCM - hypertrophic cardiomyopathy

LVH - left ventricular hypertrophy

DBP - diastolic blood pressure

DLP - dyslipidemia

PVC - ventricular extrasystole

IHD - ischemic heart disease

BMI - body mass index

ICD - short-acting insulin

TIM - thickness of the intima-media complex

TSH - glucose tolerance test

U3DG - ultrasonic dopplerography

FA - physical activity

FK - functional class

RF - risk factors

COPD - chronic obstructive pulmonary disease

CHF - chronic heart failure

HDL cholesterol - high-density lipoprotein cholesterol

LDL cholesterol - low density lipoprotein cholesterol

4KB - percutaneous coronary intervention

HR - heart rate

ECG - electrocardiography

EKS - pacemaker

Echocardiography - echocardiography

VE - respiratory minute volume

VCO2 is the amount of carbon dioxide released per unit of time;

RER (respiratory ratio) - the ratio of VCO2 / VO2;

BR - respiratory reserve.

BMS - non-drug coated stent

DES - drug eluting stent

5. Date of protocol development: year 2013.

7. Users of the protocol: general practitioners, cardiologists, interventional cardiologists, cardiac surgeons.

8. Indication of the absence of a conflict of interest: missing.

9. Definition.

ischemic heart disease- this is an acute or chronic heart disease caused by a decrease or cessation of blood supply to the myocardium due to a painful process in the coronary vessels (WHO definition 1959).

angina pectoris- this is clinical syndrome, manifested by a feeling of discomfort or pain in the chest of a compressive, pressing nature, which is most often localized behind the sternum and can radiate to the left arm, neck, lower jaw, epigastric region. The pain is provoked by physical activity, exposure to cold, heavy meals, emotional stress; resolves with rest or resolves with sublingual nitroglycerin for a few seconds to minutes.

II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND

10. Clinical classification:

Table 1 - Classification of the severity of stable angina pectoris according to the classification of the Canadian Heart Association (Campeau L, 1976)

Ischemic heart disease (abbreviated as IHD, disease code according to ICD-10-I20-I25) is a complete or partial violation of the blood supply to the heart muscle. It occurs due to the pathology of the coronary arteries. IHD, as well as ischemic stroke (ICD-10 code - I60-I69) account for approximately 90% of all heart diseases, circulatory system as well as the brain.

Reasons for the development of coronary artery disease

Classification and nomenclature

1. Angina pectoris, known to many as "angina pectoris". It is documented as - I20.
2. Acute myocardial infarction - I21.
3. Recurrent myocardial infarction - I22. This pathology is diagnosed if 28 calendar days have not passed since the moment of the attack (heart attack).
4. Various complications of acute infarction - I23.
5. Other forms of coronary artery disease have been assigned the code I24. This category previously included angina pectoris (it was listed as a separate item, has an ICD-10 code - I20) and neonatal ischemia (transferred to cardiovascular pathology, perinatal period, code - P29).
6. I25- chronic course ischemic heart disease.

Almost all items have clarifications about the duration of the disease from the onset of an attack to hospitalization or death of the patient. Doctors, in addition to the code designation of the disease, must indicate this time period. The date of onset of the disease is established from the words of the patient or his relatives.

List of diseases with ICD code 10

At the moment, the ICD codes of the tenth revision are the most relevant and are widely used by doctors around the world. For coding diseases, an alphanumeric system is used, which makes the coding structure as convenient and understandable as possible.

The ICD codes are known in all countries and are essential not only for classification but also for statistics on cases of morbidity or mortality in the health services.

angina pectoris

Particular attention, perhaps, deserves angina pectoris, colloquially known as "angina pectoris". 10-20% of people over the age of 65 experience this disease.

As noted above, previously this disease was considered one of the forms of cardiac ischemia, but now it has a separate code. Paragraph I20, in addition, includes:

• unstable angina, where angina pectoris actually belongs, ICD-10 code - I20.0;
• angina pectoris with spasm, which had documented evidence - I20.1;
• other forms of angina - I20.8;
• angina pectoris, unspecified - I2.9.

Causes of these diseases

Risk factors will be the same for almost all diseases of the cardiovascular system. The main factors are:

• male gender;
• elderly age;
• obesity;
• heredity;
• taking hormonal contraceptives;
• smoking;
• alcoholism;
• hypodynamia;
• elevated blood pressure for a long time;
• diabetes;
• constant stress;
• overwork;
• excessive physical activity;
• irrational nutrition;
• lack of vitamins and minerals.

An important cause of coronary artery disease is the ratio of blood levels of cholesterol types - high molecular weight, low molecular weight and very low molecular weight lipoproteins. It is because of the imbalance of cholesterol that atherosclerosis occurs, which further leads to coronary artery disease (ICD-10 - I20-I25) or ischemic stroke (ICD-10 - I60-I69). Often these conditions can be accompanied by a heart attack - the necrosis of part or all of an organ due to a lack of blood supply.

Sufficiently severe pathology, which is the replacement of myocardial cells with connective structures, as a consequence of myocardial infarction - postinfarction cardiosclerosis. This pathological process significantly disrupts the work of the heart itself and, as a result, the whole organism as a whole.

ICD-10 code

This disease has its own ICD code (in the International Classification of Diseases). This is I25.1 - having the name "Atherosclerotic heart disease. Coronary (th) (arteries): atheroma, atherosclerosis, disease, sclerosis.

ICD-10 code

I25.1 Atherosclerotic heart disease

Causes of postinfarction cardiosclerosis

As mentioned above, the pathology is caused by the replacement of necrotic myocardial structures with connective tissue cells, which cannot but lead to a deterioration in cardiac activity. And there are several reasons that can start such a process, but the main one is the consequences of a myocardial infarction suffered by a patient.

Cardiologists distinguish these pathological changes in the body into a separate disease belonging to the group of coronary heart diseases. Usually, the diagnosis in question appears in the card of a person who has had a heart attack, two to four months after the attack. During this time, the process of myocardial scarring is predominantly completed.

After all, a heart attack is a focal death of cells, which must be replenished by the body. Due to the circumstances, the replacement is not with analogues of heart muscle cells, but with scar-connective tissue. It is this transformation that leads to the ailment considered in this article.

Depending on the localization and scale of the focal lesion, the degree of cardiac activity is also determined. After all, "new" tissues do not have the ability to contract and are not able to transmit electrical impulses.

Due to the pathology that has arisen, stretching and deformation of the heart chambers are observed. Depending on the location of the foci, tissue degeneration can affect the heart valves.

Another cause of the pathology under consideration can be myocardial dystrophy. A change in the heart muscle, which appeared as a result of a deviation in it from the norm of metabolism, which leads to impaired blood circulation as a result of a decrease in the contractility of the heart muscle.

Trauma can also lead to such an ailment. But the last two cases, as catalysts for the problem, are much rarer.

Symptoms of postinfarction cardiosclerosis

Clinical manifestation this disease directly depends on the place of formation of necrotic foci and, accordingly, scars. That is, the larger the scarring, the more severe the symptomatic manifestations.

The symptoms are quite diverse, but the main one is heart failure. The patient is also able to feel similar discomfort:

• Arrhythmia - failure of the rhythmic work of the body.
• Progressive dyspnea.
• Decreased resistance to physical stress.
• Tachycardia is an increase in the rhythm.
• Orthopnea - breathing problems when lying down.
• There may be nocturnal attacks of cardiac asthma. After 5 - 20 minutes after the patient changes the position of the body, to a vertical one (standing, sitting), breathing is restored and the person comes to his senses. If this is not done, then against the background of arterial hypertension, which is a concomitant element of the pathology, ontogenesis can reasonably occur - pulmonary edema. Or as it is also called acute left ventricular failure.
• Attacks of spontaneous angina pectoris, while pain may not accompany this attack. This fact may manifest itself against the background of a violation of the coronary circulation.
• With damage to the right ventricle, swelling of the lower extremities may appear.
• An increase in the venous pathways in the neck can be seen.
• Hydrothorax - accumulation of transudate (non-inflammatory fluid) in the pleural cavity.
• Acrocyanosis is a bluish discoloration of the skin associated with insufficient blood supply to small capillaries.
• Hydropericardium - dropsy of the heart shirt.
• Hepatomegaly - stagnation of blood in the vessels of the liver.

Large-focal postinfarction cardiosclerosis

The large-focal type of pathology is the most severe form of the disease, leading to serious disturbances in the work of the affected organ, and the whole organism as a whole.

In this case, myocardial cells are partially or completely replaced by connective tissues. Large areas of replaced tissue significantly reduce the performance of the human pump, including these changes can affect the valve system, which only exacerbates the situation. With such a clinical picture, a timely, sufficiently deep examination of the patient is necessary, who subsequently will have to be very attentive to his health.

The main symptoms of macrofocal pathology include:

• The appearance of respiratory discomfort.
• Failures in the normal rhythm of contractions.
• The manifestation of pain symptoms in the retrosternal region.
• Increased fatigue.
• Quite noticeable swelling of the lower and upper limbs, and in rare cases, the entire body.

It is quite difficult to identify the causes of this particular type of ailment, especially if the source is a disease that has been transferred for a relatively long time. Doctors designate only a few:

• Diseases of an infectious and / or viral nature.
• Acute allergic reactions organism, to any external stimulus.

Atherosclerotic postinfarction cardiosclerosis

This type of pathology under consideration is caused by the progression of coronary heart disease by replacing myocardial cells with connective cells, due to atherosclerotic disorders of the coronary arteries.

Simply put, against the background of a long-term lack of oxygen and nutrients experienced by the heart, the division of connective cells between cardiomyocytes (muscle cells of the heart) is activated, which leads to the development and progression of the atherosclerotic process.

The lack of oxygen occurs due to the accumulation of cholesterol plaques on the walls of blood vessels, which leads to a decrease or complete blockage of the flow area of ​​the blood flow.

Even if there is no complete blockage of the lumen, the amount of blood entering the organ decreases, and, consequently, there is a shortage of oxygen by the cells. Especially this shortage is felt by the heart muscles, even with a slight load.

In people receiving heavy physical exertion, but having atherosclerotic problems with blood vessels, postinfarction cardiosclerosis manifests itself and progresses much more actively.

In turn, to reduce the clearance coronary vessels may result:

• A failure in lipid metabolism leads to an increase in plasma cholesterol levels, which accelerates the development of sclerotic processes.
• Chronically high blood pressure. Hypertension increases the speed of blood flow, which provokes blood microvortices. This fact creates additional conditions for the sedimentation of cholesterol plaques.
• Addiction to nicotine. When it enters the body, it provokes capillary spasm, which temporarily impairs blood flow and, consequently, the supply of systems and organs with oxygen. At the same time, chronic smokers have elevated blood cholesterol levels.
• genetic predisposition.
• Excess kilograms add load, which increases the likelihood of ischemia.
• Constant stress activates the work of the adrenal glands, which leads to an increase in the level of hormones in the blood.

In this situation, the process of development of the disease in question proceeds measuredly at a low speed. The left ventricle is primarily affected, since it is on it that the greatest load falls, and when oxygen starvation he is the one who suffers the most.

For some time, the pathology does not manifest itself. A person begins to feel discomfort when almost all muscle tissue is already interspersed with connective tissue cells.

Analyzing the mechanism of the development of the disease, we can conclude that it is diagnosed in people whose age has exceeded the forty-year mark.

Lower postinfarction cardiosclerosis

By virtue of its anatomical structure in the lower region of the heart is the right ventricle. It is "served" by the pulmonary circulation. He received this name due to the fact that the circulating blood captures only the lung tissue and the heart itself, without nourishing other human organs.

In a small circle, only venous blood flows. Thanks to all these factors, this area of ​​the human motor is the least affected by negative factors, which lead to the disease considered in this article.

Complications of postinfarction cardiosclerosis

As a consequence of developing postinfarction cardiosclerosis, other ailments may develop in the future:

• Atrial fibrillation.
• The development of an aneurysm of the left ventricle, which has passed into a chronic state.
• Diverse blockade: atrioventricular.
• The likelihood of various thrombosis, thromboembolic manifestations increases.
• Paroxysmal ventricular tachycardia.
• Ventricular extrasystole.
• Complete atrioventricular block.
• Sick sinus syndrome.
• Tamponade of the pericardial cavity.
• In severe cases, an aneurysm may rupture and, as a result, the patient may die.

This reduces the quality of life of the patient:

• Breathlessness intensifies.
• Decreased performance and load capacity.
• Violations of cardiac contractions are observed.
• Rhythm breaks appear.
• Usually, ventricular and atrial fibrillation can be observed.

In the case of the development of an atherosclerotic disease, side symptoms can also affect non-cardiac areas of the victim's body.

• Loss of sensation in the limbs. The feet and phalanges of the fingers are especially affected.
• Cold limb syndrome.
• Can develop atrophy.
• Pathological disorders can be affected vascular system brain, eyes and other areas.

Sudden death in postinfarction cardiosclerosis

As unfortunate as it sounds, but a person suffering from the disease in question has a high risk of asystole (cessation of bioelectrical activity, leading to cardiac arrest), and as a result, the onset of sudden clinical death. Therefore, a relative of this patient should be prepared for such an outcome, especially if the process is running sufficiently.

Another reason that entails a sudden onset of death, and which is a consequence of postinfarction cardiosclerosis, is considered to be an exacerbation of the pathology and the development of cardiogenic shock. It is he who, with untimely assistance (and in some cases with it) becomes Starting point the onset of death.

Fibrillation of the ventricles of the heart, that is, a scattered and multidirectional contraction of individual bundles of myocardial fibers, is also capable of provoking lethality.

Based on the foregoing, it should be understood that a person who has been diagnosed with the diagnosis in question needs to carefully monitor his health, regularly monitoring his blood pressure, heart rate and rhythm, and regularly visit the attending cardiologist. This is the only way to reduce the risk of sudden death.

Diagnosis of postinfarction cardiosclerosis

• In case of suspected heart disease, including the one discussed in this article, the cardiologist prescribes a number of studies to the patient:
• Analysis of the patient's history.
• Physical examination by a doctor.
• He tries to establish whether the patient has an arrhythmia, and how stable it is.
• Conducting electrocardiography. This method quite informative and can "tell" a qualified specialist a lot.
• Ultrasound examination of the heart.
• The purpose of rhythmocardiography is an additional non-invasive electrophysiological study of the heart, with the help of which the doctor receives a record of the rhythm variability of the blood-pumping organ.
• Positron emission tomography (PET) of the heart is a radionuclide tomographic study that allows you to find the localization of hypoperfusion foci.
• Coronary angiography is a radiopaque method of examining the coronary artery of the heart for the diagnosis of coronary heart disease using x-rays and contrast fluid.
• An echocardiogram is one of the ultrasound examination methods aimed at studying the morphological and functional changes in the heart and its valvular apparatus.
• Establishing the frequency of manifestations of heart failure.
• Radiography makes it possible to determine the change in the dimensional parameters of the biological mechanism under study. Basically, this fact is revealed due to the left half.
• To diagnose or exclude transient ischemia, in some cases a person has to undergo stress tests - tests.
• A cardiologist, if the medical institution has such equipment, can prescribe Holter monitoring, which allows for daily monitoring of the patient's heart.
• Conducting ventriculography. This is a more narrowly focused examination, an x-ray method for evaluating the chambers of the heart, in which a contrast agent is injected. In this case, the image of the contrasted ventricle is recorded on a special film or other recording device.

Postinfarction cardiosclerosis on ECG

ECG or as it stands for - electrocardiography. This technique medical examination aimed at analyzing the bioelectrical activity of myocardial fibers. The electrical impulse, having arisen in the sinus node, passes, due to a certain level of conductivity, through the fibers. In parallel with the passage of the impulse signal, a contraction of cardiomyocytes is observed.

During electrocardiography, thanks to special sensitive electrodes and a recording device, the direction of the moving impulse is registered. Thanks to this, a specialist can get a clinical picture of the work of individual structures of the cardiac complex.

An experienced cardiologist, having an ECG of a patient, is able to assess the main parameters of work:

• level of automatism. The ability of various departments of the human pump to independently generate an impulse of the required frequency, which has an exciting effect on myocardial fibers. There is an assessment of extrasystole.
• The degree of conduction is the ability of cardio fibers to conduct the signal from the place of its occurrence to the contracting myocardium - cardiomyocytes. It becomes possible to see if there is a lag in the contractile activity of a particular valve and muscle group. Usually, a mismatch in their work occurs just when the conductivity is disturbed.
• Evaluation of the level of excitability under the influence of the created bioelectric impulse. At healthy condition under the influence of this irritation, a certain group of muscles contract.

The procedure itself is painless and takes a little time. Taking into account all the preparation, this will take 10 - 15 minutes. In this case, the cardiologist receives a quick, fairly informative, result. It should also be noted that the procedure itself is not expensive, which makes it accessible to the general population, including the low-income.

The preparatory activities include:

• The patient needs to expose the torso, wrists, arms and legs.
• Location data medical worker carrying out the procedure are wetted with water (or soapy water). After that, the passage of the pulse improves and, accordingly, the level of its perception by the electrical appliance.
• Ankle, wrist and chest tucks and suction cups are superimposed, which will catch the necessary signals.

At the same time, there are accepted requirements, the implementation of which must be strictly controlled:

• A yellow electrode is attached to the left wrist.
• On the right is red.
• A green electrode is placed on the left ankle.
• On the right is black.
• Special suction cups are placed on the chest in the region of the heart. In most cases, there should be six.

After receiving the charts, the cardiologist evaluates:

• The height of the voltage of the cloves of the QRS indicator (failure of ventricular contractility).
• The level of bias of the criterion S - T. The probability of their decrease below the isoline of the norm.
• Estimation of T peaks: the degree of decrease from the norm, including the transition to negative values, is analyzed.
• Varieties of tachycardia of different frequencies are considered. Flutter or atrial fibrillation is assessed.
• The presence of blockades. Evaluation of failures in the conductive capacity of the conductive bundle of cardiotissues.

The electrocardiogram should be deciphered by a qualified specialist who, according to various kinds of deviations from the norm, is able to add up the entire clinical picture of the disease, while localizing the focus of the pathology and deriving the correct diagnosis.

Treatment of postinfarction cardiosclerosis

Taking into account the fact that this pathology belongs to rather complex manifestations and due to the responsible function that this organ performs for the body, the therapy for stopping this problem must necessarily be of a complex nature.

These are non-drug and drug methods, if necessary, surgical treatment. Only timely and full-scale treatment can achieve a positive resolution of the problem with ischemic disease.

If the pathology is not yet very advanced, then by means of medical correction it is possible to eliminate the source of the deviation, restoring normal functioning. By acting directly on the links of pathogenesis, for example, the source of atherosclerotic cardiosclerosis (forming cholesterol plaques, blockage of blood vessels, arterial hypertension, and so on), it is quite possible to cure the disease (if it is in its infancy) or significantly support normal metabolism and functioning.

It should also be noted that self-treatment in this clinical picture is absolutely unacceptable. Assign medications possible only with a confirmed diagnosis. Otherwise, the patient can bring even more harm, exacerbating the situation. In this case, already irreversible processes can be obtained. Therefore, even the attending physician - a cardiologist, before prescribing therapy, must be absolutely sure of the correctness of the diagnosis.

With the atherosclerotic form of the disease in question, a group of medicines is used to fight heart failure. These are pharmacological agents how:

• Metabolites: rickavit, midolate, mildronate, apilac, ribonosine, glycine, milife, biotredin, antisten, riboxin, cardionate, succinic acid, cardiomagnyl and others.
• Fibrates: normolip, gemfibrozil, gevilon, ciprofibrate, fenofibrate, ipolipid, bezafibrate, regulip and others.
• Statins: recol, mevacor, cardiostatin, pitavastatin, lovasterol, atorvastatin, rovacor, pravastatin, apexstatin, simvastatin, lovacor, rosuvastatin, fluvastatin, medostatin, lovastatin, choletar, cerivastatin and others.

The metabolic agent glycine quite well accepted by the body. The only contraindication to its use is hypersensitivity to one or more components of the drug.

The drug is administered in two ways - under the tongue (sublingually) or located between upper lip and gums (transbuccal) until complete resorption.

The drug is prescribed dosage depending on the age of the patient:

Babies who are not yet three years old - half a tablet (50 ml) two to three times throughout the day. This mode of administration is practiced for one to two weeks. Further, for seven to ten days, half a tablet once a day.

Children who are already three years old and adult patients are prescribed a whole tablet two to three times during the day. This mode of administration is practiced for one to two weeks. If therapeutically necessary, the treatment course is extended up to a month, then a monthly break and a second course of treatment.

The lipid-lowering drug gemfibrozil attributed to the attending physician inside half an hour before a meal. The recommended dosage is 0.6 g twice a day (in the morning and evening) or 0.9 g once a day (in the evening). The tablet should not be crushed. The maximum allowable dosage is 1.5 g. The duration of treatment is one and a half months, and if necessary, more.

To contraindications this medicine include: primary biliary cirrhosis of the liver, increased intolerance to the patient's organisms of the components of gemfibrozil, as well as the period of pregnancy and lactation.

The lipid-lowering agent fluvastatin is administered regardless of the meal, whole, without chewing, together with a small amount of water. It is recommended to use in the evening or just before bedtime.

The starting dosage is selected individually - from 40 to 80 mg daily and is adjusted depending on the effect achieved. With a mild stage of the violation, a decrease to 20 mg per day is allowed.

The contraindications of this medication include: acute ailments affecting the liver, the general serious condition of the patient, individual intolerance to the components of the drug, pregnancy, lactation (in women) and childhood, since the absolute safety of the drug has not been proven.

Are used the same angiotensin-converting enzyme inhibitors(APF blockers): olivin, normapress, invoril, captopril, minipril, lerin, enalapril, renipril, calpiren, corandil, enalakor, miopril and others.

ACE blocker enalapril taken regardless of food. With monotherapy, the starting dose is a single dose of 5 mg daily. If a therapeutic effect not observed, after a week or two it can be increased to 10 mg. The drug should be taken under constant monitoring by a specialist.

With normal tolerance, and if necessary, the dosage can be increased to 40 mg daily, spaced into one or two doses throughout the day.

The maximum allowable daily amount is 40 mg.

When co-administered with a diuretic, the second should be stopped a couple of days before the introduction of enalapril.

The drug is contraindicated in case of hypersensitivity to its components, during pregnancy and lactation.

AT complex therapy enter and diuretics: furosemide, kinex, indap, lasix and others.

Furosemide in the form of tablets is taken on an empty stomach, without chewing. The maximum allowable daily amount for adult patients is 1.5 g. The starting dosage is determined at the rate of 1-2 mg per kilogram of the patient's weight (in some cases, up to 6 mg per kilogram is allowed). The next dose of the drug is not allowed earlier than six hours after the initial injection.

Edema indicators in chronic heart failure are stopped by a dosage of 20 to 80 mg daily, divided into two to three inputs (for an adult patient).

Contraindications to use may be such diseases: acute renal and / or hepatic dysfunction, coma or pre-coma, impaired water and electrolyte metabolism, severe glomerulonephritis, decompensated mitral or aortic stenosis, children's age (up to 3 years), pregnancy and lactation.

To activate and normalize heart contractions, drugs such as lanoxin, dilanacin, strophanthin, dilacor, lanicor or digoxin are often taken.

cardiotonic, cardiac glycoside, digoxin is assigned a starting amount of up to 250 mcg daily (patients whose weight does not exceed 85 kg) and up to 375 mcg daily (patients whose weight exceeds 85 kg).

For elderly patients, this amount is reduced to 6.25 - 12.5 mg (a quarter or half a tablet).

It is not recommended to administer digoxin in a person with a history of such diseases as glycoside intoxication, AV blockade of the second degree or complete blockade, in the case of Wolff-Parkinson-White syndrome, as well as in case of hypersensitivity to the drug.

If the complex of drug and non-drug therapy does not bring the expected effect, the council appoints surgery. The range of operations carried out is quite wide:

• Expansion of the narrowed coronary vessels, allowing to normalize the volume of passing blood.
• Shunting is the creation of an additional path around the affected area of ​​a vessel using a shunt system. The operation is performed on the open heart.
• Stenting is a minimally invasive intervention aimed at restoring the normal lumen of the affected arteries by implanting a metal structure into the vessel cavity.
• Balloon angioplasty is an intravascular bloodless method of surgical intervention used to eliminate stenoses (narrowings).

The main methods of physiotherapy have not found their application in the protocol for the treatment of the disease in question. Only electrophoresis can be used. It is applied topically to the heart area. In this case, drugs from the group of statins are used, which, thanks to this therapy, are delivered directly to the sore spot.

Well-proven sanatorium-resort therapy with mountain air. As an additional method, a specialized physiotherapy, which will increase the overall tone of the body and normalize blood pressure.

Psychotherapy with a diagnosis of postinfarction cardiosclerosis

Psychotherapeutic therapy - system therapeutic effect on the psyche and through the psyche on the human body. It will not interfere with the relief of the disease considered in this article. After all, how well set up, in terms of treatment, a person largely depends on his attitude in therapy, the correct implementation of all the doctor's prescriptions. And as a result - a higher degree of the result.

It should only be noted that this therapy (psychotherapeutic treatment) should only be carried out by an experienced specialist. After all, the human psyche is a delicate organ, damage to which can lead to an unpredictable ending.

Nursing care for postinfarction cardiosclerosis

The duties of nursing staff for the care of patients diagnosed with postinfarction cardiosclerosis include:

• General care for such a patient:
  • Replacement of bedding and underwear.
  • Sanitation of the premises with ultraviolet rays.
  • Ventilation of the room.
  • Compliance with the instructions of the treating doctor.
  • Carrying out preparatory measures before diagnostic studies or surgery.
  • Teaching the patient and his relatives the correct administration of nitroglycerin during a painful attack.
  • Teaching the same category of people to keep a diary of observations, which will subsequently allow the attending doctor to trace the dynamics of the disease.
• On the shoulders of nursing staff falls the responsibility of conducting conversations on the topic of caring for their health and the consequences of ignoring problems. The need for timely intake of medications, control of the daily regimen and nutrition. Mandatory daily monitoring of the patient's condition.
• Help in finding motivation to change lifestyle that would reduce risk factors for pathology and its progression.
• Conducting counseling training on disease prevention.

Dispensary observation in postinfarction cardiosclerosis

Clinical examination is a set of active measures that provides systematic monitoring of a patient who has been diagnosed with the diagnosis considered in this article.

Indications for medical examination are such symptoms:

• The occurrence of angina pectoris.
• Progression of angina pectoris.
• With the appearance of heart pain and shortness of breath at rest.
• Vasospastic, that is, spontaneous pain symptoms and other symptoms of angina pectoris.

All patients with these manifestations are subject to mandatory hospitalization in specialized cardiology departments. Dispensary observation with postinfarction cardiosclerosis includes:

• Round-the-clock monitoring of the patient and identification of his anamnesis.
• Diverse research and consultation of other specialists.
• Patient care.
• Establishing the correct diagnosis, the source of pathology and the appointment of a treatment protocol.
• Monitoring the susceptibility of the patient's body to a particular pharmacological drug.
• Regular monitoring of the state of the body.
• Sanitary - hygienic and economic measures.

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Promoting a healthy lifestyle means reducing the risk of any disease, including the prevention of post-infarction cardiosclerosis.

To these events, nutrition and the lifestyle that is inherent this person. Therefore, people who seek to maintain their health as long as possible should follow simple rules:

• Nutrition should be complete and balanced, rich in vitamins (especially magnesium and potassium) and trace elements. Portions should be small, but it is advisable to eat five to six times a day, without overeating.
• Monitor your weight.
• Do not allow large daily physical exertion.
• Complete sleep and relaxation.
• Stressful situations must be avoided. The state of a person must be emotionally stable.
• Timely and adequate treatment of myocardial infarction.
• A special medical-physical complex is recommended. Therapeutic walking.
• Balneotherapy - treatment with mineral waters.
• Regular dispensary monitoring.
• Spa treatment.
• Walking before going to bed and being in a ventilated room.
• Positive attitude. If necessary - psychotherapy, communication with nature and animals, watching positive programs.
• Preventive massages.

In more detail it is worth dwelling on nutrition. From the diet of such a patient, coffee and alcoholic beverages, as well as products that excite the cells of the nervous and cardiovascular systems, should disappear:

• Cocoa and strong tea.
• Minimize your salt intake.
• Limited - onions and garlic.
• Fatty varieties of fish and meat.

It is necessary to remove from the diet products that provoke increased gas secretion in the human intestine:

• All beans.
• Radish and radish.
• Milk.
• Cabbage, especially sour.
• Offal should disappear from the diet, provoking the deposition of "bad" cholesterol in the vessels: internal organs animals, liver, lungs, kidneys, brains.
• Smoked meats and spicy dishes are not allowed.
• Exclude from the diet products of supermarkets with a large number of "E-shek": stabilizers, emulsifiers, various dyes and chemical flavor enhancers.

Forecast of postinfarction cardiosclerosis

The prognosis of postinfarction cardiosclerosis directly depends on the location of pathological changes in the myocardium, as well as the level of severity of the disease.

If the left ventricle, which provides blood flow, has been damaged big circle blood circulation, while the blood flow itself is reduced by more than 20% of the norm, the quality of life of such patients undergoes a significant deterioration. With such a clinical picture, drug treatment acts as a maintenance therapy, but can no longer completely cure the disease. Without an organ transplant, the survival of such patients does not exceed five years.

The pathology under consideration is directly related to the formation of scar tissues that replace healthy cells that have undergone ischemia and necrosis. This substitution leads to the fact that the area of ​​focal lesions completely “drops out” of the workflow, the remaining healthy cells try to pull a large load against which heart failure develops. The more affected areas, the more severe the degree of pathology, it is more difficult to eliminate the symptoms and the source of the pathology, leading the tissues to recovery. After diagnosis, medical therapy aimed at maximizing the elimination of the problem and the prevention of recurrence of a heart attack.

The heart is a human motor that requires some care and attention. Only when all preventive measures you can expect from him a long normal operation. But if there was a failure and a diagnosis was made - postinfarction cardiosclerosis, then treatment should not be delayed in order to prevent the development of more serious complications. In such a situation, one should not rely on an independent solution to the problem. Only with a timely diagnosis and taking adequate measures under the constant supervision of a qualified specialist, one can speak of a high efficiency of the result. This approach to the problem will improve the quality of life of the patient, and even save his life!

The situation when the blood supply to the myocardium is disturbed due to obstruction of the blood arteries is called coronary heart disease (CHD). Lack of oxygen creates an imbalance between the coronary blood circulation and the metabolic processes of the heart muscle. This condition can create the appearance acute pathology- myocardial infarction, or take a stable protracted character in the form of an exacerbation of angina pectoris.

Etiology of angina pectoris, classification

Angina pectoris is a clinical syndrome of manifestation of coronary artery disease. It is not an independent disease, but consists of many symptoms. pain. The localization site is concentrated in the sternum, in the area where the heart is located. In this focus, discomfort is felt in the form of squeezing, heaviness, burning, pressure.

Modern medicine, according to the features of the clinical course of the pathology, combines angina pectoris into 3 options, which have their own codes in the international classification of diseases:

Any of these conditions is evidence of unstable angina.

1. Vasospastic angina, ICD code -10: I20.1, takes possession of a person as a result of a sharp vasospasm that occurs from their blockage. Pain can happen at rest, in sleep, in the cold, and is not always characteristic of coronary artery disease, but is caused by other ailments:
   1. Stenosis of the aorta and heart valves.
   2. Anemia of a high degree.
   3. Overgrowth of heart tissue - cardiosclerosis.

Causes and symptoms

Having dealt with the classification of pathology, you can answer in more detail the question of what FC 3 exertional angina is.

Restriction of the patency of the circulatory system as a result of atherosclerosis is the main cause of FC 3 exertional angina. When its decrease is 50-70%, an imbalance occurs between myocardial oxygen demand and its delivery. Clinical picture disease is manifested by frequent attacks of angina pectoris. Various factors influence the disease:

• localization of stenosis;
• length;
• the number of affected vessels.

In addition to atherosclerotic obstruction, the formation of blood clots and spasms of the arterial tree is not excluded in the pathogenesis. The following factors can act as provocateurs of angina pectoris 3 FC:

• obesity;
• smoking;
• a significant amount of cholesterol in the blood;
• diabetes;
• severe emotional stress of any kind;
• chronic stress;
• physical inactivity - a sedentary lifestyle;
• hypertension;
• rapid blood clotting, contributing to the formation of blood clots;

From the above reasons, the patient develops angina pectoris. But for the development of an attack, provoking factors are needed, among the main influences are physical activity, emotional experiences or adverse weather conditions.

What is FC 3 in the development of angina pectoris? These are characteristic and common signs of pathology:

• Physical activity takes on a limited character, so as not to provoke an attack of angina pectoris.
• The frequency of manifestation of pain is almost daily. Her companions are tachycardia, shortness of breath, cold sweat, changes in blood pressure, arrhythmia.
• Quick in action "Nitroglycerin" is not always effective.
• Remission does not last long, only after a course of hospital therapy.
• During an attack, the ECG will show ischemia and diffuse changes in the myocardium.

• The medical history often contains a heart attack or chronic aneurysm of the heart;
• In the presence of a symptom of atherosclerosis of the aorta and other arteries;
• Atypical angina without pain, but with shortness of breath, arrhythmia and other symptoms.
• Heart rhythm disturbances.
• Heart failure.
• Hypertension in combination with coronary artery disease.
• Diagnostics detects pathogenic vascular branches with narrowing up to 75%.

Important! IHD angina pectoris 3 FC is considered by doctors as a disability.

The presence of specific clinical symptoms will assist in the diagnosis of pathology:

• Tension, burning, constriction in the focus of the heart.
• The place of occurrence of symptoms is the left side of the trunk: sternum, shoulder, shoulder blade, arm, neck. The right half of the body is not excluded, which is less common.
• Duration of pain in the interval >2 and<15 минут.
• Conditions for development suddenly or at the apogee of activity: walking, climbing to the floor, plentiful food, overcoming resistance to gusts of wind.
• Attack relief options: refusal to exercise, relieving pain, or a Nitroglycerin tablet.

Stable angina pectoris FC 3 differs from its counterparts in the ability to predict the onset of an attack. Limitations in physical activity are known to the patient. Therefore, compliance with their norms is a guarantee of the absence of pain. In case of warning symptoms that appear, it is necessary to have "Nitroglycerin" on hand. Despite the limitations of the load, the patient is able to serve himself and does not need someone else's help, as in the case of FC 4.

Diagnostics

A complaint of pain in the focus of the sternum, which is the result of specific actions of a person, has a subjective criterion in making a diagnosis. It is necessary to weed out other ailments that can give such an effect.

Instrumental techniques and laboratory tests will confirm the correct diagnosis of pathology. These include:

• blood biochemistry;
• scintigraphy;
• Ultrasound of the heart;
• load tests;
• ECG Holter monitoring;
• coronary angiography.

After completing the examination, there will no longer be questions about what it is in the diagnosis of coronary artery disease: angina pectoris 3 FC.

Treatment, prognosis and prevention

Having determined the diagnosis, the appropriate therapy is selected. It consists in the systematic use of drugs:

• A number of nitrates that can prevent an attack of angina pectoris or stop it. The most common "Nitroglycerin".
• Antiplatelet agents to eradicate the formation of blood clots: "Clopidogrel", "Aspirin".
• Statins. Cholesterol drugs: Atorvastatin, Cerivastatin, Fluvastatin, Lovastatin, Mevastatin, Pitavastatin, Pravastatin, Rosuvastatin, Simvastatin.
• ACE inhibitors. They fight arterial hypertension, chronic heart failure (CHF), complicated by angina pectoris: Kapoten, Enam, Privinil, Lotensil, Monopril and others.
• β-blockers, divided into groups, are used for CHF and after a heart attack. They should be selected individually and only on the recommendation of a doctor, because they have a detrimental effect on the body without the correct dosage.

In addition to them, drugs of another action are also used: the structural analogue of gamma-butyrobetaine "Metonat", the metabolic agents "Capicor".

With angina pectoris, surgical treatment is possible:

• coronary angioplasty;
• shunting of the affected vessels.

If you do not pay attention to the treatment of angina pectoris, then there is a risk of death due to extensive heart attacks. The regularity of the use of therapeutic therapy according to the prognosis contributes to an improvement in the quality of life, despite the limitation of the patient's activity.

Effective prevention lies in the elimination of risk factors. Diet, weight loss, blood pressure control and everything else that is useful to the body is offered. When diagnosing angina pectoris, secondary prevention is carried out. Here you should avoid emotions, stress, dropping tension to a minimum. Do not forget to take "Nitroglycerin" before physical effort. Following the advice of your treating cardiologist allows you to increase your life without seizures.

Causes, diagnosis and treatment of stable angina

Stable angina pectoris is a characteristic clinical syndrome, the specificity of which is manifested by the occurrence of paroxysmal pain in the retrosternal region, turning into pain of a compressive, aching or pressing nature, due to a certain level of load. The main symptoms of this pathology of a stable nature are considered to be a feeling of heaviness, pressure and pain behind the sternum during physical or emotional stress, pain in the heart that subsides when the load is removed, or after taking nitroglycerin.

• Causes of pathology
• Disease classification
• Symptoms of a pathological condition
• Diagnostics
• Treatment of the disease
• Forecast and prevention

This type of pathology, according to the classification, is recognized as the most common clinical manifestation of coronary artery disease with a steady trend in the course, in the absence of deterioration within 2-4 weeks. In cardiology, the disease is referred to as a type of angina pectoris, which is manifested by a characteristic symptom - dull pain, which increases over time with increasing load, and disappears when it is removed. This is a type of disease in which an examination is necessarily carried out regarding the disability of the patient.

This condition is due to the fact that during stress of physical or emotional origin, the arteries are not able to provide the high demand of the heart muscle for oxygen consumption. Such a process provokes an acute transient ischemic pathology of the myocardium, as well as the formation of the initial stage of an attack.

Medical statistics have revealed an age and gender pattern - this disease affects about 70% of men in the age group from 50 to 60 years, in men under 50 years of age - the percentage of patients is much higher. Women tend to suffer from this disease less frequently, and between the ages of 65 and 75.

Causes of pathology

Cardiologists consider diagnosed coronary artery disease and atherosclerosis of the heart vessels to be the main causes of pathology, which provokes severe stenosis over time (in 90-97% of cases). An attack is possible under the condition of narrowing of the gaps in the coronary arteries in the range from 50% to 75%.

A sharp decrease in blood supply to the heart muscle can cause a spasm that lasts for a long time - in the area of ​​\u200b\u200bthe small coronary vessels of the heart (coronary). This is caused by local hypersensitivity of the muscle cells of the vessel walls to various stimulating impulses, as well as to changes in the level of ANS tone. In elderly patients, an attack of an anginal nature can not only provoke an exacerbation of coronary artery disease, but also be a reflex accompaniment of attacks of such systemic diseases as pancreatitis, cholelithiasis, esophageal hernia, neoplasm of the cardiac section of the stomach.

As a rule, stable exertional angina develops with certain systemic diseases and pathologies:

• connective tissue damage of rheumatoid origin,
• arterial dystrophy associated with amyloidosis,
• ischemic heart disease,
• heart failure due to aortic stenosis or cardiomyopathy.

In addition, some provoking circumstances can also cause an attack - excessive eating, long exposure to the air in cold weather with a sharp wind, stressful situations.

According to statistics, certain diseases and conditions are also risk factors that provoke the development of the disease:

• high blood pressure;
• obesity;
• hypercholesterolemia;
• diabetes;
• heredity,
• alcohol and smoking abuse;
• asthenic syndrome and physical inactivity;
• women are characterized by early menopause, use of COCs for a long time.

When diagnosing this disease, it is necessary to take into account - the more pronounced the pathological condition of the coronary arteries, the faster an attack can develop, as a result of provoking factors.

Disease classification

The loads carried by patients, the reaction to them, the rate of manifestation of an attack, the clinical picture during its course determine the classification of the pathology.

Class I includes a mild form of the disease, which is accompanied by initial manifestations. The occurrence of seizures is rare, and only with pronounced loads, severe stress. Symptoms disappear immediately after the removal of stress. In such cases, a disability examination is not prescribed.

Class II pathology is characterized by the appearance of paroxysmal pain during fast walking over long distances, when climbing (uphill, on the floor). Signs can be activated when freezing, after eating, with little stress. But pain in the heart can be stopped by removing the load. Limit walking - no higher than 4 km / h.

Class III according to the ICD is characterized by more severe symptoms - a clear and obvious decrease in physical mobility, retrosternal pain even when slowly walking for short distances, shortness of breath when lifting 1-2 flights. In this case, the attack can be stopped by taking nitroglycerin.

Class IV forms the group of the most severe patients. They are not able to physically move, because the attack begins instantly with any load. Symptoms appear with any movement, and often at rest, and the examination reveals not only the patient's incapacity for work, but sometimes disability.

Symptoms of a pathological condition

This disease is generally accompanied by a series of paroxysmal symptoms that occur during physical and emotional stress. The degree of their manifestation depends on the clinical picture of the course of the disease, its duration and the background on which it develops.

Patients with a diagnosed pathology complain of manifestations that are often similar to those of coronary artery disease - heaviness in the region of the heart, obvious and severe retrosternal pain - bursting, pressing or burning. Pain in the heart can be given to the shoulder of the left hand, between the shoulder blades, in the digestive tract, sometimes in the back of the neck.

Characteristically, the patient looks during such an attack - not being able to take a full breath, he presses his palm or fist to the sternum, trying to reduce his heartbeat and breathe in full force. In addition, patients strive to sit or lie down, since in this position the symptoms are somewhat reduced.

The pain attack is accompanied by characteristic manifestations:

• fear of dying
• fatigue,
• profuse sweating,
• nausea, sometimes with vomiting,
• pressure surges,
• manifestations of tachycardia - increased heart rate.

The strength of the attack gradually increases, it can last from 1 minute to 15 minutes, the pain in the heart instantly disappears after reducing the load or after taking a nitroglycerin tablet (usually after five minutes). In a situation where the attack lasts more than 15-20 minutes, it can be assumed that it caused a myocardial infarction (International Classification of Diseases).

Patients of a young age often note a phenomenon, conditionally called “passing the pain”, which is characterized by a decrease or disappearance of pain with increasing load, which is explained by the lability of vascular tone.

Diagnostics

With typical manifestations of the disease, the diagnosis according to the ICD is easily established in 75-80% of cases according to the anamnesis, the results of the cardiogram, after which doctors have the opportunity to prescribe the correct treatment for stable angina pectoris. The criterion of the disease is the direct connection of seizures with stress and stressful situations, and their decrease in a calm state, or after a nitroglycerin tablet. In implicit cases, if it is impossible to immediately establish a diagnosis, an examination is prescribed.

Characteristic of the disease is the absence of changes in the electrocardiogram of the heart at rest in many patients. At the same time, on the cardiogram made at the time of the attack, a sign, as in IHD, is considered to be a decrease in the ST segment, inversion of the T wave and a pronounced rapid rhythm.

If it is impossible to immediately establish a diagnosis, or there is insufficient information about the history of the disease of stable angina pectoris, it is necessary to conduct daily ECG monitoring, which allows you to fix the alternation of pain / absence, and to establish the moment and time of the duration of ischemic changes.

In order to clarify the clinical picture, bicycle ergometry is performed, and the results of the treadmill test are used. These studies help to give a full assessment of the degree of stress that the patient is able to endure before the onset of an attack. During these studies, the frequency of SS and the results of the cardiogram are constantly monitored, and blood pressure is monitored.

A positive load test during bicycle ergometry is considered when fixing the displacement of the ST segment by more than one mm, with a duration of more than 0.08 seconds, or the onset of an attack. If it is not possible to conduct a bicycle ergometry or perform a treadmill test, then doctors prescribe a transesophageal pacemaker (PE pacing) - a non-invasive therapy method in order to artificially speed up the heart rate and provoke an anginal attack.

Echocardiography in a calm state is carried out as part of the differential diagnosis, by analogy with the diagnosis of coronary artery disease, to fix the appearance of pain of non-coronary origin. More informative and sensitive.

The use of stress echocardiography makes it possible to obtain more information and identify ischemic disorders, determine the localization of areas with ventricular akinesia, as well as identify hypo and dyskinesia, which was not observed in a calm state.

Methods of laboratory diagnostics in this disease, in contrast to the detection of symptoms of coronary artery disease, are of an auxiliary nature. They are considered effective and effective for determining concomitant functional diseases and pathologies, such methods allow you to identify risk factors, and help to exclude other grounds for the appearance of pain.

For a complete and detailed determination of the state of the coronary vascular system, it is advisable to use CT coronary angiography, since such a study allows doctors to identify coronary atherosclerosis, assess the degree of stenosis, which ultimately allows choosing the optimal pathology treatment regimen.

Treatment of the disease

The main goal of therapeutic measures is to reduce the frequency of attacks, relieve their intensity until the main symptoms disappear, and, most importantly, to remove the consequences, to prevent the occurrence of complications - various heart pathologies and sudden death. Drug therapy consists in prescribing courses of taking drugs from the main groups - nitrates, beta-blockers and calcium channel blockers, which can reduce myocardial requests for oxygen consumption.

Nitroglycerin invariably has a positive effect at a certain stage of the disease, and it is advisable to take it to stop attacks, as in the syndrome of coronary artery disease, with pathologies of classes 1-3 according to the classification. Nitrates, which have a prolonged action, are prescribed by doctors for preventive purposes, to increase the periods between attacks. Their reception is recommended in cases where the attacks are repeated no more than once every 5-7 days, and are accompanied by burning pains in the heart. A good effect is given by lipid-lowering drugs and antiplatelet agents.

Surgical treatment of stable angina pectoris (according to the ICD) consists in myocardial revascularization, which is usually understood as coronary artery bypass grafting, but today there are already known cases of this procedure being carried out by stenting.

Forecast and prevention

A disease of this nature is dangerous because it can “doze off” for a long time and not show any signs, especially a tendency to progress, moreover, even a serious medical examination cannot establish the onset of the disease. With proper treatment methods, and constant monitoring of the patient by a cardiologist, the prognosis is quite favorable.

Medical statistics confirm the favorable clinical picture, and in 97% of cases - a return to normal life (subject to the recommendations of doctors, the absence of excessive stress, stress and the right lifestyle).

To reduce the number of risk factors for recurrent attacks, and the transition of pathology to myocardial infarction, doctors recommend a special diet with restriction of eating fatty foods, sugar, and pickles. Important for such patients is the constant monitoring of blood pressure (if necessary, stabilization of pressure) and the correction of a possible violation of carbohydrate metabolism.

Attacks of coronary artery disease that occur as a result of stressful situations and physical exertion, which increases the heart's need for oxygen, is called angina pectoris. The disease manifests itself with pain, discomfort, a feeling of tightness and burning behind the sternum. Angina pectoris code according to ICD-10 mainly occurs in older people, children and young people under 30 years old, prone to angina attacks, make up less than a percent.

FC 1 - loads are tolerated normally, often the latter is not even aware of his illness. Attacks of pain occur only with a significant overstrain.

FC 2 - some limitation of activity, pain and shortness of breath occur when climbing an inclined plane and steps, in cold weather, with a headwind, emotional overexcitation.

FC 3 - an attack of angina pectoris occurs even with a slight load - normal walking, climbing one floor.

FC 4 - any load - simple movements cause an attack, which happens even at rest.

Angina pectoris code according to ICD-10 is divided into stable and unstable. The first is much better controlled and treated, since an attack is predictable when certain factors occur. An attack of unstable angina, the ICD-10 code happens out of the blue, it is impossible to predict and prepare for it.

Causes of angina pectoris

The main reason is atherosclerosis, that is, the adherence of atherosclerotic plaques to the walls of blood vessels, which gradually bury the lumen and cause insufficient blood supply to the heart, which means its oxygen starvation.

The following factors cause atherosclerosis:

Signs of an angina attack:

1. Pain.
2. Change in heart rate and pulse.
3. Paleness or cyanosis of the skin.
4. Violent cold sweat.
5. Weakness.
6. Anxiety.
7. Dyspnea.

The duration of the attack is no more than a quarter of an hour.

How to stop an attack

1. Stop all movement, sit down if possible, but do not lie down.
2. Place a nitroglycerin tablet under the tongue, if the attack is severe, then two, but not more than five pieces can be used, and then in exceptional cases when medical assistance is not available.

If taking nitroglycerin does not stop the attack and the symptoms continue to worsen, then an immediate call for an ambulance is required, as this indicates the occurrence of a myocardial infarction.

Diagnosis of angina pectoris

The patient is interviewed, his heartbeat is heard, the medical history is viewed.

Medical treatment of angina pectoris

In addition to medicines, the complex also uses folk remedies, which include herbal infusions, useful vitamin-strengthening compounds.

Surgical treatment

If conservative therapy does not give significant results, then the patient is prescribed surgical intervention:

• Coronary artery bypass grafting - an anastomosis is applied to the site of blockage of the artery, that is, a bypass for blood is made, which improves the blood supply to the heart.
• Coronary angioplasty - expansion of the artery and the installation of a stent, which will prevent re-stenosis.

Patients are also prescribed a change in lifestyle: quitting smoking, exercise therapy, eliminating junk food from the diet, normalizing weight, avoiding stress and nervous strain. All this makes it easier for the body to endure stress, which will reduce the frequency of attacks.