Condition after stenting ICb code 10. ICb code ischemic heart disease

Right

• It includes the right ventricle and the right atrium. This part of the heart is engaged in pumping venous blood, in which the oxygen content is low. Carbon dioxide comes here from all organs and tissues of the body.
• There is a tricuspid valve on the right side of the heart that connects the atrium to the ventricle. The latter is also connected to the pulmonary artery by the valve of the same name.

The heart is located in a special bag that performs a shock-absorbing function. It is filled with fluid that lubricates the heart. The volume of the bag is usually 50 ml. Thanks to her, the heart is not subjected to friction with other tissues and works normally.

The heart works in cycles. Before contracting, the organ is relaxed. In this case, passive filling with blood occurs. Both atria then contract, pushing more blood into the ventricles. Then the atria return to a relaxed state.

The ventricles then contract, pushing blood into the aorta and pulmonary artery. After that, the ventricles relax, and the systole phase is replaced by the diastole phase.

The heart has a unique function - automatism. This organ is capable of aggregating nerve impulses without the help of external factors, under the influence of which the contraction of the heart muscle occurs. No other organ human body does not have such a function.

The pacemaker located in the right atrium is responsible for the generation of impulses. It is from there that impulses begin to flow to the myocardium through the conduction system.

The coronary arteries are one of the most important components that ensure the work and vital activity of the heart. It is they who deliver the necessary oxygen and nutrients to all heart cells.

If the coronary arteries have good patency, then the body works in a normal mode, it does not overstrain. If a person has atherosclerosis, then the heart does not work at full strength, it begins to feel a serious lack of oxygen. All this provokes the appearance of biochemical and tissue changes, which subsequently lead to the development of coronary artery disease.

Self-diagnosis

It is very important to know the symptoms of IHD. They usually appear at the age of 50 and older. It is possible to identify the presence of coronary artery disease during physical activity.

Symptoms of this disease include:

• angina pectoris (pain in the center of the chest);
• lack of air;
• heavy breath of oxygen;
• very frequent contractions of the heart muscle (over 300 times), leading to a stop in the movement of blood.

Some patients with IHD are asymptomatic. They do not even suspect the presence of an ailment when a myocardial infarction occurs.

To understand what is the likelihood of developing a disease in a patient, he should use a special cardio test “Is your heart healthy?”.

People who want to understand if they have coronary artery disease go to a cardiologist. The doctor conducts a dialogue with the patient, asking questions, the answers to which help to form a complete picture of the patient. So the specialist discovers possible symptoms studies risk factors for the disease. The more of these factors, the higher the probability of having coronary artery disease in a patient.

The manifestations of most of the factors can be eliminated. This helps to prevent the disease from developing, while the likelihood of complications is also reduced.

Avoidable risk factors include:

• diabetes;
• high blood pressure;
• smoking;
• elevated cholesterol.

The attending physician also examines the patient. Based on the information received, he appoints the passage of examinations. They help to come to the final diagnosis.

The methods used include:

• ECG with stress test;
• chest x-ray;
• a biochemical blood test, including the determination of cholesterol and glucose in the blood.

The doctor, suspecting the patient has a serious lesion of the arteries, which requires urgent surgery, prescribes another type of study - coronary angiography. Next, the type of surgical intervention is determined.

It could be:

• angioplasty;
• coronary artery bypass grafting.

In less severe cases, medical treatment is used.

It is important that the patient turns to the doctor for help in time. The specialist will do everything so that the patient does not develop any complications.

To avoid the development of the disease, the patient must:

Preventive measures

To prevent IHD, you need to follow 3 rules:

Massage for coronary heart disease

A patient with coronary artery disease can supplement the treatment with aromatherapy massage. In the room where the patient sleeps, you need to put a special lamp. It will fill the air with various aromas of oils. Lavender, mandarin, ylang-ylang, lemon balm are best suited.

Massage chest do not need to do every day, it should be episodic. Instead of massage oil, you need to use peach, corn or olive oil.

A tablespoon of any of them is mixed with one of the following formulations (1 drop of each ingredient):

• oils of geranium, marjoram and frankincense;
• neroli, ginger and bergamot oils;
• oils of clary sage, bergamot and ylang-ylang.

Massage should be done by first applying the resulting mixture to the left pectoral muscle and on top of it. Movements should be light, smooth, without strong pressure.

Any way surgical treatment coronary disease is highly effective. The severity of shortness of breath decreases, angina pectoris decreases or completely disappears. Each method surgical treatment There are indications and contraindications. For the treatment of coronary heart disease are used: coronary artery bypass grafting and ...

Ischemic heart disease is one of the most common pathologies of cardio-vascular system in developed countries. It is a lesion of the heart, which is caused by an absolute or relative violation of the blood supply, which occurred as a result of a circulatory disorder in the coronary ...

Insufficient supply of oxygen to the heart due to narrowing of the arteries and their clogging with plaque leads to the development of coronary heart disease (CHD). There can be many reasons: alcohol abuse, improper diet, a sedentary lifestyle that contributes to the development of physical inactivity, constant stress and ...

For the first time, the principle of using the ECG was put into circulation in the 70s of the 19th century. This was done by an Englishman named W. Walter. Now, when almost 150 years have passed since that moment, the method of taking indicators of the electrical activity of the heart has changed significantly, becoming more reliable and informative, but the basic principles ...

The principles of treatment and prevention are closely related to the use of herbal medicine and diet. Proper nutrition and folk remedies in the treatment of coronary heart disease can dramatically improve the patient's condition. Principles of therapy Causes of coronary artery disease are different, but almost all are based on malnutrition and unhealthy...

Determining the IHD code according to ICD 10 is always a long and laborious process. The disease is located in the class of pathologies of the circulatory system. At its core, coronary artery disease is a complex of pathologies that are characterized by a violation of the blood supply to the heart or its individual sections.

Accordingly, ischemia can be acute or chronic. When coding coronary disease, one should take into account the fact that coronary artery disease is often combined with arterial hypertension, and this requires additional clarification of the diagnosis.

In addition, during the setting of a particular disease in the PICS block according to ICD 10 should take into account the duration of the ischemic attack. At the same time, to maintain statistical records of morbidity, the time interval from the onset of ischemia to the admission of the patient to the hospital is taken into account. When assessing overall mortality, the time from the onset of an attack to death is estimated.

Encoding features

The code for coronary heart disease in ICD 10 ranges from I20 to I25. This includes the following nosological units:

• I20 - represented by angina pectoris, which is subdivided into stable angina and unstable form (strain), as well as unspecified forms of pathology;
• I21 - acute coronary syndrome or myocardial infarction, which is divided into points depending on the location of the lesion and the depth of necrotic phenomena;
• I22 - re-infarction, which implies the appearance of signs of myocardial necrosis within 28 days from the moment of the development of the previous infarction;
• I23 - complications of a heart attack (for example, the formation of heart defects, hemopericardium, rupture of some structures);
• I24 - so In the ICD 10 IHD block, other forms of nosology are coded (for example, Dressler's syndrome or coronary thrombosis without signs of infarction);
• I25 - chronic ischemia of the heart, which is also divided into many points (atherosclerosis, aneurysm, myocardial infarction and other forms).

Coronary artery disease means that, for whatever reason, the heart does not receive enough blood to function properly.

In adults, coronary artery disease is much more common than in children, due to malnutrition, bad habits accumulation of harmful substances in the body and other external factors. At the same time, such a coding of the pathology is necessary in order to adequately distribute the basic principles of treatment and diagnosis. a large number forms of IBS.

PROFILE COMMISSION FOR THE SPECIALTY "PATHOLOGICAL ANATOMY" OF THE MINISTRY OF HEALTH OF THE RUSSIAN FEDERATION

RUSSIAN SOCIETY OF PATHOLOGISTS

FSBI "RESEARCH INSTITUTE OF HUMAN MORPHOLOGY"

SBEE DPO "RUSSIAN MEDICAL ACADEMY OF POSTGRADUATE EDUCATION" MINISTRY OF HEALTH OF RUSSIA

Moscow State Medical and Dental University named after A.I. EVDOKIMOVA» MINISTRY OF HEALTH OF RUSSIA

SBEE HPE "Russian National Research Medical University named after N.I. Pirogov" MINISTRY OF HEALTH OF RUSSIA

SBEE HPE "FIRST ST PETERSBURG STATE MEDICAL UNIVERSITY NAMED AFTER ACADEMICIAN I.P. PAVLOV» MINISTRY OF HEALTH OF RUSSIA

Wording
pathological diagnosis
with ischemic heart disease
(class IX "diseases of the circulatory system" ICD-10)

Moscow - 2015

Compiled by:

Frank G.A., Academician of the Russian Academy of Sciences, Doctor of Medical Sciences, Professor, Head of the Department pathological anatomy GBOU DPO RMAPO of the Ministry of Health of Russia, chief freelance pathologist of the Ministry of Health of Russia, First Vice-President of the Russian Society of Pathologists;

Zayratyants O.V., Doctor of Medical Sciences, Professor, Head of the Department of Pathological Anatomy, Moscow State Medical University named after A.I. A.I. Evdokimov of the Ministry of Health of Russia, Vice-President of the Russian and Chairman of the Moscow Society of Pathologists;

Shpektor A.V., Doctor of Medical Sciences, Professor, Head of the Department of Cardiology, FPDO, Moscow State Medical University named after A.I. A.I. Evdokimova of the Ministry of Health of Russia, chief freelance cardiologist of the Department of Health of the city of Moscow;

Kaktursky L.V., Corresponding Member of the Russian Academy of Sciences, Doctor of Medical Sciences, Professor, Head of the Central Clinical Laboratory of the Research Institute of Human Morphology, Chief Freelance Pathologist of Roszdravnadzor, President of the Russian Society of Pathologists;

Mishnev O.D., Doctor of Medical Sciences, Professor, Head of the Department of Pathological Anatomy and Clinical Pathological Anatomy, SBEI HPE Russian National Research Medical University. N.I. Pirogov of the Ministry of Health of Russia, Vice-President of the Russian Society of Pathologists;

Rybakova M.G., Doctor of Medical Sciences, Professor, Head of the Department of Pathological Anatomy, State Budgetary Educational Institution of Higher Professional Education First St. Petersburg State Medical University. acad. I.P. Pavlov of the Ministry of Health of Russia, chief freelance pathologist of the Committee on Healthcare of St. Petersburg;

Chernyaev A.L., Doctor of Medical Sciences, Professor, Head of the Pathology Department of the Federal State Budgetary Institution Research Institute of Pulmonology of the Federal Medical and Biological Agency of Russia;

Orekhov O.O., Candidate of Medical Sciences, Head of the Pathological Anatomical Department of City Clinical Hospital No. 67, Chief Freelance Pathologist of the Moscow City Health Department;

Losev A.V., Candidate of Medical Sciences, Head of the Pathological Anatomical Department of the Regional State Budgetary Institution of Healthcare clinical Hospital Ministry of Health of the Tula Region, chief freelance pathologist of the Ministry of Health of the Tula Region and the Ministry of Health of Russia in the Central Federal District of the Russian Federation.

Abbreviations

• CABG - coronary artery bypass grafting
• IHD - ischemic heart disease
• MI - myocardial infarction
• ICD-10 - International Statistical Classification of Diseases and Related Health Problems, Tenth Revision
• MNB - international nomenclature of diseases
• ACS - acute coronary syndrome
• CVD - cardiovascular diseases
• PCI - percutaneous coronary intervention

Methodology

Methods used to collect/select evidence:

Search in electronic databases.

Description of the methods used to collect/select evidence:

Methods used to assess the quality and strength of evidence:

• - expert consensus
• - development of ICD-10
• - study of the MNB.

Methods used to formulate recommendations:

Expert Consensus

Consultations and expert assessment:

The preliminary version was discussed at a meeting of the specialized commission on the specialty "pathological anatomy" of the Ministry of Health of Russia on February 19, 2015, at a meeting of the Moscow Society of Pathologists on April 21, 2015, after which it was posted on the website of the Russian Society of Pathologists (www.patolog.ru) for a wide discussion, so that specialists who did not take part in the profile commission and the preparation of recommendations have the opportunity to familiarize themselves with them and discuss them. The final approval of the recommendations was carried out at the VIII Plenum of the Russian Society of Pathologists (May 22-23, 2015, Petrozavodsk).

Working group:

For final editing and quality control of the recommendations, they were re-analyzed by members working group who came to the conclusion that all the remarks and comments of the experts were taken into account, the risk of systematic errors in the development of recommendations was minimized.

Method formula:

The rules for formulating the final clinical, pathoanatomical and forensic diagnoses, filling in a statistical accounting document - a medical death certificate for coronary heart disease in accordance with the requirements of the current legislation of the Russian Federation and ICD-10 are given. The domestic rules for the formulation of the diagnosis and diagnostic terminology were adapted to the requirements and codes of the ICD-10.

Indications for use:

Unified rules for formulating the final clinical, pathoanatomical and forensic diagnosis, issuing a medical certificate of death in coronary heart disease in accordance with the requirements of the current legislation of the Russian Federation and ICD-10 throughout the country are necessary to ensure interregional and international comparability of statistical data on incidence and causes death of the population.

Logistics:

International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) with additions for 1996-2015.

"" - approved by order of the Ministry of Health of the Russian Federation No. 241 of 08/07/1998

annotation

Clinical recommendations are intended for pathologists, forensic experts, cardiologists and doctors of other specialties, as well as for teachers of clinical departments, graduate students, residents and senior students of medical universities.

The recommendations are the result of a consensus between clinicians, pathologists and forensic experts and are aimed at improving the quality of diagnosis of nosological units included in the group concept of "coronary heart disease" (CHD) and their statistical accounting among the causes of death in the population. The purpose of the recommendations is to introduce into practice unified rules for formulating a pathoanatomical diagnosis and issuing medical certificates of death in coronary artery disease in accordance with the provisions of the Federal Law of November 21, 2011 No. Russian Federation» and the requirements of the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10). The rules apply to final clinical and forensic diagnoses in connection with the underlying general requirements for the formulation and the need for their comparison (comparison) in the course of clinical and expert work. Examples of the construction (formulation) of pathoanatomical diagnoses and the execution of medical death certificates are given.

Clinical guidelines are based on a summary of literature data and the authors' own experience. The authors are aware that the construction and formulation of diagnoses may change in the future as new scientific knowledge is accumulated. Therefore, despite the need to unify the formulation of the pathoanatomical diagnosis, some proposals may give rise to discussion. In this regard, any other opinions, comments and wishes of specialists will be accepted by the authors with gratitude.

Introduction

Diagnosis is one of the most important objects of standardization in health care, the basis for quality management of medical services, documentary evidence of a doctor's professional qualifications. The reliability of data provided by health authorities on morbidity and mortality of the population depends on the unification and strict adherence to the rules for formulating diagnoses and issuing medical death certificates. The responsibility assigned to pathologists and forensic experts is especially high.

The recommendations are the result of a consensus between clinicians, pathologists and forensic experts and are aimed at improving the quality of diagnosis of nosological units included in the group concept of "coronary heart disease" (CHD) and their statistical accounting among the causes of death in the population.

Their need is due to:

• - statistical data on the multiple and disproportionate excess of mortality rates from cardiovascular diseases (CVD), coronary artery disease and myocardial infarction (MI) in Russia compared with the EU and the USA, which may indicate different approaches to their diagnosis and accounting. Thus, diseases of the CHD group in Russia are selected as the initial cause of death 3 times more often than in Europe. As a result of overdiagnosis of chronic forms of coronary artery disease, cardiosclerosis variants account for the vast majority (up to 20%) of all nosological units - the initial causes of death. Their proportion among deaths in the IHD group reaches 90%, many times higher than the mortality rates from these diseases in the EU and the USA. The mortality rate is artificially inflated both from coronary artery disease in general, reaching 30%, and from CVD, exceeding 60% among all causes of death, which is 3 times higher than in the EU and the USA.
• - introduction in recent years into the international clinical practice new definitions and classifications of acute coronary syndrome (ACS) and MI.
• - introduction of more than 160 changes and updates to the ICD-10 by WHO experts over the past decades.
• - the publication of the Central Research Institute of Organization and Informatization of Healthcare of the Ministry of Health of the Russian Federation and the Ministry of Health of Russia of new recommendations for coding according to ICD-10 diseases of class IX "Diseases of the circulatory system".

Cardiac ischemia

IHD (or coronary heart disease) - a group (generic) concept that includes pathological processes (nosological forms) arising from acute or chronic myocardial ischemia (inconsistency in the level of supply of oxygenated blood to the level of demand for it in the heart muscle), caused by spasm, narrowing or obstruction of the coronary arteries during their atherosclerosis.

IHD in ICD-10 is included in class IX "Diseases of the circulatory system", which combines a large number of group (generic) concepts and nosological units identified both on the basis of their etiology and pathogenesis, and based on medical and social criteria(many are pathogenetically complications of atherosclerosis, arterial hypertension, diabetes mellitus). In particular, such the group concept is IBS. It includes a number of nosological forms, namely, types of angina pectoris, MI, cardiosclerosis, etc. In ICD-10, even such nosological units as acute and repeated MI are divided into separate forms according to the localization of the pathological process and some other criteria, which is necessary take into account when coding.

As independent nosological forms, hypertension and secondary arterial hypertension with the diseases that caused them cannot be diagnosed in the diagnosis if nosological units from the IHD group are diagnosed (as well as from the groups of cerebrovascular diseases, ischemic lesions of the intestines, limbs and other main arteries).

Class IX includes a number of terms, such as "hypertensive disease", "atherosclerotic heart disease", "past myocardial infarction", etc. There are domestic analogues for them: "hypertensive disease" or " arterial hypertension”, “atherosclerotic cardiosclerosis” or “diffuse small-focal cardiosclerosis”, “post-infarction cardiosclerosis” or “large-focal cardiosclerosis”. When formulating a diagnosis, it is permissible to use the terms adopted in domestic classifications, and for issuing a medical death certificate - their counterparts from ICD-10 with the corresponding codes.

Not used in diagnoses, as they represent group and / or unspecified pathological conditions in IHD (given in ICD-10 not for their use in a detailed diagnosis): acute coronary heart disease, unspecified (I24.9), atherosclerotic cardiovascular disease, as described (I25 .0), chronic ischemic heart disease, unspecified (I25.9) .

Cannot appear as underlying disease pathological processes that are complications or manifestations of IHD and some other nosological forms (syndromes, symptoms): current complications of acute myocardial infarction (I23.0-I23.8), heart failure (I50), arrhythmia variants (I44-I49), in addition to congenital arrhythmias and conduction disorders leading to fatal asystole, most of the pathological processes from the group "complications and ill-defined heart diseases" (I51), acute (but not chronic) aneurysm of the heart, pulmonary embolism (thromboembolism pulmonary artery, except for obstetric practice for which ICD-10 has a special class XV "Pregnancy, childbirth and the postpartum period" and corresponding codes), cor pulmonale (acute or chronic), pulmonary hypertension (except for primary, idiopathic, which is a nosological form), phlebothrombosis (but not thrombophlebitis), etc. .

As a nosological unit - the main disease in lethal outcomes (the original cause of death) are not used the following pathological processes present in the IHD group in ICD-10 class IX: coronary thrombosis not leading to myocardial infarction (I24.0), disorders of the circulatory system after medical procedures, not elsewhere classified (I97).

With any mention in the headings of the clinical diagnosis of atherosclerosis of the coronary arteries, it is advisable (if appropriate vascular studies have been performed, for example, angiography), and in pathoanatomical or forensic diagnoses, it is necessary to indicate:

• - localization and degree of maximum stenosis of specific arteries (in %),
• - localization and features (variant of complication) of unstable ("easily injured") atherosclerotic plaques.

Additionally, it is also advisable to indicate the stage of atherosclerosis and its degree (the area of ​​the lesion). There are 4 stages of atherosclerosis: I - lipid spots, II - lipid spots and fibrous plaques, III - lipid spots, fibrous plaques and "complicated lesions" (hemorrhages in fibrous plaques, atheromatosis, their ulceration, thrombotic complications), IV - the presence of atherocalcinosis along with with previous changes. There are 3 degrees of severity of atherosclerosis of the aorta and arteries: moderate, damage to 25% of the area of ​​the intima, pronounced, the area of ​​the lesion is from 25% to 50%, pronounced, the area of ​​the lesion is more than 50%.

It is unacceptable to replace the term "atherosclerosis" with the terms "calcification" or "sclerosis" of the artery, since such lesions can be caused not only by atherosclerosis, but also by vasculitis or hereditary diseases.

Nosological units from the CHD group are excluded if the detected myocardial damage (angina pectoris syndrome, MI, cardiosclerosis) is not caused by atherosclerosis of the coronary arteries, but by other causes (coronary and non-coronary necrosis and their outcomes). In such cases, myocardial damage is indicated in the diagnosis under the heading "Complications of the underlying disease", or, when the logic of constructing a diagnosis dictates, as part of the manifestations of the underlying disease.

When formulating a diagnosis, one of the nosological forms that make up the IHD should be selected. It is unacceptable to simultaneously indicate several such units in different sections of the diagnosis, for example, MI under the heading "Main disease", and post-infarction cardiosclerosis - "Concomitant disease", or post-infarction and atherosclerotic cardiosclerosis even in one heading.

The modern clinical classification of IHD does not fully correspond to the morphological and ICD-10:

1. Acute forms of IHD:

1.1. Acute (sudden) coronary death;

1.2. Acute coronary syndrome:

1.2.1. Unstable angina;

1.2.2. MI without ST segment elevation (non-ST-elevation myocardial infarction - NSTEMI);

1.2.3. MI with ST segment elevation (ST-elevation myocardial infarction - STEMI).

2. Chronic forms IHD:

2.1. Angina pectoris (except unstable),

2.2. Atherosclerotic (diffuse small focal) cardiosclerosis;

2.3. Ischemic cardiomyopathy;

2.4. Large-focal (post-infarction) cardiosclerosis;

2.5. Chronic aneurysm of the heart.

2.6. Other rare forms (painless myocardial ischemia, etc.).

Excluded from use and absent in the classifications and ICD-10 the term "focal myocardial dystrophy"(“acute focal ischemic myocardial dystrophy”), proposed by A.L. Myasnikov (1965). In the diagnosis, instead of this term, MI (as its ischemic stage) should be indicated, and not always as part of IHD.

Angina pectoris is a group of clinically distinguished nosological units included in the ICD-10 (I20.0-I20.9). Its morphological substrate can be a variety of acute and chronic changes in the myocardium. In the final clinical, pathoanatomical and forensic diagnoses, it is not used.

Ischemic cardiomyopathy(code I25.5) - an extreme manifestation of prolonged chronic myocardial ischemia with its diffuse lesion (severe diffuse atherosclerotic cardiosclerosis, similar to dilated cardiomyopathy). The diagnosis of ischemic cardiomyopathy is established with severe dilatation of the left ventricular cavity with impaired systolic function (ejection fraction of 35% or less). The use of this diagnosis is advisable only in specialized cardiological medical institutions.

Diagnosis "chronic aneurysm of the heart"(in ICD-10 - "heart aneurysm" with code I25.3) does not require additional indication of the presence of postinfarction cardiosclerosis if it is limited to the walls of the aneurysm. Diagnosis post-infarction (large-focal) cardiosclerosis does not require additional indication of the presence of atherosclerotic (diffuse small-focal) cardiosclerosis.

Painless myocardial ischemia(asymptomatic ischemia, code I25.6) is diagnosed in a patient when episodes of myocardial ischemia are detected on the ECG, but in the absence of angina attacks. Like angina pectoris, silent myocardial ischemia does not may appear in the final clinical, pathological or forensic diagnosis.

Syndrome X in the clinical diagnosis, a patient is established who, in the presence of angina attacks, does not show coronary artery lesions (angiographically, etc.), there are no signs of vasospasm, and other causes of angina pectoris syndrome that are not included in the IHD group are excluded. "Stunned" (stunned) myocardium- dysfunction of the left ventricle of the heart after episodes of acute ischemia without myocardial necrosis (including after myocardial revascularization). "Hibernating", "asleep" (hibernating) myocardium- the result of a long-term decrease in coronary perfusion while maintaining the viability of the myocardium (but with its pronounced dysfunction). In the diagnosis, the terms "syndrome X", "stunned" and "hibernating" myocardium are not used, there are no ICD-10 codes for them.

In foreign literature, instead of terms "atherosclerotic cardiosclerosis" and "diffuse small-focal cardiosclerosis" use essentially the same concepts: "diffuse or small-focal atrophy of cardiomyocytes with interstitial myocardial fibrosis" or "atherosclerotic heart disease". Last term included in ICD‑10 (code I25.1) .

Unjustified overdiagnosis of atherosclerotic (diffuse small-focal) or post-infarction (large-focal) cardiosclerosis as the main or competing, or combined disease should be avoided. So, often this diagnosis is erroneously established with an insufficiently professionally performed autopsy and a superficial analysis of thanatogenesis, especially in observations of acute death, when acute (sudden) coronary death is the true primary cause of death. It is also important to differentiate brown myocardial atrophy (with severe perivascular sclerosis and myofibrosis) in various severe diseases and in the dead of old age, and diffuse small-focal cardiosclerosis as a form of coronary artery disease. Often nosological units from the group chronic ischemic heart disease, which do not play a significant role in thanatogenesis, are incorrectly recorded as competing or combined diseases. They should be listed under the heading "Concomitant diseases" (examples 1 - 5).

• Main disease: Bilateral focal confluent pneumonia in the VI-X lung segments with abscess formation (bacteriologically - S. pneumoniae, date) J13.
• Background disease: Chronic alcohol intoxication with multiple organ damage: …. (F10.1)
• Complications of the underlying disease: Acute general venous plethora. Cerebral edema.
• Accompanying illnesses: Diffuse small focal cardiosclerosis. Stenosing atherosclerosis of the coronary arteries of the heart (2nd degree, stage II, stenosis mainly of the branches of the left artery up to 50%). Atherosclerosis of the aorta (3rd degree, stage IV).

Medical death certificate

I. a) Cerebral edema.

b) Pneumococcal bilateral pneumonia (J 13)

II. Chronic alcohol intoxication (F10.1).

• Main disease: Atherosclerotic (dyscirculatory) encephalopathy. Stenosing atherosclerosis of the arteries of the brain (2nd degree, II stage, stenosis of predominantly internal carotid arteries up to 50%) (I67.8).
• Background disease: Hypertension: arteriolosclerotic nephrosclerosis (I10).
• Cachexia: brown myocardial atrophy, liver, skeletal muscle.
• Accompanying illnesses: Atherosclerosis of the aorta (3rd degree, stage IV).

Medical death certificate

I. a) Cachexia

b) Atherosclerotic (dyscirculatory) encephalopathy (I67.8).

• Main disease: Intracerebral non-traumatic hematoma in the subcortical nuclei of the right hemisphere of the brain (hematoma volume). Atherosclerosis of the arteries of the brain (2nd degree, II stage, stenosis predominantly of the left middle cerebral artery up to 30%) (I61.0).
• Background disease: Hypertension: concentric myocardial hypertrophy (heart weight 430 g, wall thickness of the left ventricle 1.8 cm, right - 0.3 cm), arteriolosclerotic nephrosclerosis (I10).
• Complications of the underlying disease: Breakthrough of blood in the cavity of the right lateral and third ventricles of the brain. Edema of the brain with the dislocation of its trunk.
• Accompanying illnesses: Large focal cardiosclerosis posterior wall of the left ventricle. Stenosing atherosclerosis of the coronary arteries of the heart (2nd degree, stage II, stenosis mainly of the branches of the left artery up to 50%). Atherosclerosis of the aorta (3rd degree, stage IV).

Medical death certificate

b) A breakthrough of blood into the ventricles of the brain.

c) Intracerebral hematoma (I61.0).

II. Hypertension (I10).

• Main disease: Ischemic cerebral infarction (atherothrombotic) in the frontal, parietal lobes and subcortical nuclei of the left hemisphere (the size of the focus of necrosis). Stenosing atherosclerosis of cerebral arteries (3rd degree, stage III, stenosis of predominantly anterior and middle left cerebral artery up to 30%, red obstructive thrombus 2 cm long and unstable atherosclerotic plaque of the left middle cerebral artery) (I63.3).
• Complications of the underlying disease: Edema of the brain with the dislocation of its trunk.
• Accompanying illnesses: Diffuse small-focal cardiosclerosis. Stenosing atherosclerosis of the coronary arteries of the heart (2nd degree, stage II, stenosis predominantly of the right artery up to 50%). Atherosclerosis of the aorta (3rd degree, stage IV).

Medical death certificate

I. a) Edema of the brain with dislocation of its trunk.

• Main disease: Residual effects after the transferred intracerebral hemorrhage(date - according to the medical history): brown cyst in the subcortical nuclei of the right hemisphere of the brain. Stenosing atherosclerosis of the arteries of the brain (2nd degree, II stage, stenosis predominantly of the right posterior, middle and basilar cerebral arteries up to 30%) (I69.1).
• Background disease: Hypertension: concentric myocardial hypertrophy (heart weight 390 g, wall thickness of the left ventricle 1.7 cm, right 0.2 cm), arteriolosclerotic nephrosclerosis (I10).
• Complications of the underlying disease: Bilateral total focal confluent pneumonia (etiology).
• Accompanying illnesses: Large focal cardiosclerosis posterior wall of the left ventricle. Stenosing atherosclerosis of the coronary arteries of the heart (2nd degree, stage II, stenosis predominantly of the left circumflex artery up to 50%). Atherosclerosis of the aorta (3rd degree, stage IV).

Medical death certificate

I. a) Focal confluent pneumonia.

b) Residual effects after intracerebral hemorrhage (I69.1).

II. Hypertension (I10).

Acute coronary syndrome

The term "acute coronary syndrome" (ACS) was proposed by V. Fuster et al. (1985), but its definition has undergone a number of changes in recent years. Currently ACS is a group clinical concept within IHD, which combines various manifestations of acute myocardial ischemia due tocomplicated by unstable atherosclerotic plaque of the coronary artery of the heart. The introduction of the concept of ACS into practice led to the exclusion of the term "acute coronary insufficiency", which still appears in the ICD-10 in the group "other acute forms of coronary artery disease" with the general code I24.8. Terms such as "preinfarction condition" and "acute coronary insufficiency" are not used in the diagnosis.

The ACS includes the following nosological forms:

Unstable angina;

MI without ST segment elevation (non-ST-elevation myocardial infarction - NSTEMI);

MI with ST segment elevation (ST-elevation myocardial infarction - STEMI).

They can end in acute (sudden) coronary (cardiac) death, which in some classifications is included in the ACS. However, it should be borne in mind that acute coronary, and, moreover, cardiac death is not limited to ACS, as well as MI. The symptom previously used in the clinic in the form of the appearance of a pathological Q wave on the ECG is no longer a criterion for the diagnosis and classification of ACS. ACS, as a group concept, which is absent in the ICD-10, cannot appear in the diagnosis. This is a preliminary diagnosis, a “logistic” concept, indicating the need for certain emergency medical and diagnostic measures. With a fatal outcome, unstable angina pectoris cannot be indicated in the diagnosis. In the final clinical, pathological or forensic diagnosis, either acute (sudden) coronary death (ICD-10 code - I24.8) or MI (ICD-10 codes - I21.-) should be recorded, depending on the specific situation. and I22.-). In pathoanatomical and forensic diagnoses, ST segment changes in MI are indicated only if there are relevant data in the final clinical diagnosis, with reference "according to the card of an inpatient or outpatient", "according to the medical history").

The reason for the development of ACS is an acutely developed partial (with unstable angina and MI without ST segment elevation) or complete occlusion (with MI with ST segment elevation) of the coronary artery of the heart by a thrombus with complicated unstable atherosclerotic plaque. Complications of an unstable atherosclerotic plaque include hemorrhage into the plaque, erosion or rupture, separation of its cover, thrombus, thrombo- or atheroembolism of the distal parts of the same artery. Clinical criteria for diagnosing the causes of ACS in terms of damage to the coronary arteries of the heart are limited by the concepts of "complicated unstable atherosclerotic plaque" or "atherothrombosis", which are often used as synonyms. However, it should be clarified that endothelial damage with the development of coronary artery thrombosis can also be observed in atherosclerotic plaques that do not meet the morphological criteria for their instability. In this regard, from a general pathological position, it is more correct to speak of "complicated atherosclerotic plaque".

Complicated (usually unstable) atherosclerotic plaque of the coronary artery of the heart is an obligatory morphological criterion for the diagnosis of nosological forms included in ACS. It is important to note that stenosis of the coronary arteries by atherosclerotic plaques before the development of their complications in 50% of patients is insignificantly expressed and is less than 40%. Due to autothrombolysis or thrombolytic therapy, autopsy may no longer detect thrombi of the coronary arteries of the heart diagnosed during life (angiographically, etc.). Even without thrombolytic therapy after 24 hours, blood clots persist in only 30% of patients. Therefore, at autopsy, the detection of a complicated unstable atherosclerotic plaque, even without coronary artery thrombosis, is of fundamental importance.

The definitions of the concepts of ACS and type 1 MI (see below) dictate the requirements for the study of the coronary arteries of the heart at autopsy: it is imperative to cut the coronary arteries longitudinally, limiting only transverse sections is unacceptable. It is advisable to use the method of opening the heart according to G. G. Avtandilov. In pathoanatomical and forensic diagnoses, it is mandatory to indicate the location, type (stable, unstable) and nature of complications of atherosclerotic plaques, the degree of stenosis of specific arteries, and a description of the stage and degree (area) of atherosclerotic lesions of the arteries is optional.

So, for example, the entry is unacceptable: “Acute MI (localization, prescription, size). Atherosclerosis of the coronary arteries of the heart (2nd degree, II stage, stenosis up to 30%, thrombosis of the left coronary artery). An example of a recommended entry could be the following wording: “Acute MI (localization, prescription, size). Stenosing atherosclerosis of the coronary arteries of the heart (complicated unstable atherosclerotic plaque with a rupture of the tire, a red obstructive thrombus 1 cm long of the left coronary artery at a distance of 1.5 cm from its mouth; atherosclerotic plaques, stenosing the lumen of the left circumflex artery predominantly up to 40%).

Morphological verification of focal myocardial ischemia is necessary for pathoanatomical diagnosis of nosological forms in the composition of ACS. Although irreversible necrotic changes in cardiomyocytes develop already after 20-40 minutes of ischemia, the rate of development of necrosis is affected by the state of collaterals and microvasculature, as well as by the cardiomyocytes themselves and individual sensitivity to hypoxia. In addition, macro- and microscopic morphological signs of necrosis that do not require the use special methods diagnostics, appear no earlier than after 4-6 hours (up to 12 hours).

If myocardial ischemia of any origin is suspected, a macroscopic test is mandatory, for example, with nitrosine tetrazolium or potassium tellurite. Histological diagnosis of myocardial ischemia is less specific and more time-consuming, depending on right choice suspicious for ischemia area of ​​the myocardium and research methods. More reliable is polarizing microscopy, which can, to a certain extent, replace the macroscopic sample.

It should be borne in mind that positive results macroscopic samples or relatively specific histological changes appear approximately 30 minutes after the onset of acute myocardial ischemia. They are also not a criterion for qualifying the focus of ischemia or necrosis as a nosological form of myocardial damage from the IHD group.

Acute (sudden) coronary death

Under the term "acute (sudden) coronary death"in the clinic, they mean sudden death within one hour (according to other definitions - from 6 to 12 hours) from the onset of the first symptoms (signs) of myocardial ischemia in IHD. In the ICD-10, it is included in the group "other acute forms of coronary artery disease" (code I24.8). Pathological or forensic diagnosis of acute (sudden) coronary death is established method of excluding other causes of death based on clinical and morphological analysis. It is necessary to exclude focal myocardial ischemia. In cases where there are clinical and laboratory data on ACS or MI, and a complicated atherosclerotic plaque of the coronary arteries and focal myocardial ischemia are detected at autopsy, type I MI, its ischemic stage, is diagnosed. If an autopsy reveals coronary or non-coronary focal myocardial ischemia not associated with IHD, the diseases that caused it are diagnosed, which become the main disease.

concept"acute (sudden) cardiac death" is defined as a sudden "cardiac" death (primary circulatory arrest), unexpected in nature and time of occurrence, even in the case of a previously established heart disease, the first manifestation of which is loss of consciousness within one hour (according to other definitions - from 6 to 12 hours.) from the onset of the first symptoms. More often it is caused by lethal arrhythmias ( ventricular tachycardia ventricular fibrillation, primary ventricular fibrillation, bradyarrhythmias with asystole). In the clinic, the terms "acute cardiac death" and "acute coronary death" are often used as synonyms, and acute (sudden) cardiac death is a broader concept, a clinical syndrome for any heart damage. However in ICD-10, the term "acute (sudden) cardiac death" excludes acute coronary death and the presence of coronary artery disease . Diagnosis "acute (sudden) cardiac death" (ICD-10 code - I46.1) - "diagnosis of exclusion", allowed after the absolute exclusion of the violent nature of death, acute coronary death, any heart disease and other nosological forms, when the nature of the pathological process and the corresponding morphological substrate underlying the heart lesion cannot be established (examples 6, 7).

• Main disease: Acute coronary death(Let's say the term "Sudden coronary death"). Foci of uneven myocardial blood filling in the interventricular septum. Stenosing atherosclerosis of the coronary arteries of the heart (3rd degree, stage II, stenosis of up to 50% of the branches of the left and right arteries) (I24.8).
• Complications of the underlying disease: Ventricular fibrillation (according to clinical data). Acute general venous plethora. Liquid blood in the cavities of the heart and the lumen of the aorta. Edema of lungs and brain. Small punctate hemorrhages under the epicardium and pleura.
• Accompanying illnesses: Chronic calculous cholecystitis, stage of remission.

Medical death certificate

I. a) Acute coronary death (let's say the term "sudden coronary death") (I24.8).

• Main disease: Sudden cardiac death. Ventricular fibrillation (according to clinical data) (I46.1).
• Complications of the underlying disease: Acute general venous plethora. Liquid blood in the cavities of the heart and main vessels. Edema of lungs and brain.
• Accompanying illnesses: Chronical bronchitis

Medical death certificate

I. a) Sudden cardiac death (I46.1).

myocardial infarction

MI is coronarogenic (ischemic) necrosis of the myocardium, which can be both a nosological form as part of IHD, and a manifestation or complication of various diseases or injuries accompanied by impaired coronary perfusion (coronaritis, thrombosis and thromboembolism of the coronary arteries, their developmental anomalies, etc. .) .

Modern definition, criteria clinical diagnostics and classification of IM, called "Third universal definition of myocardial infarction" were the result of the 3rd international consensus reached in 2012 between the European Society of Cardiology, the American College of Cardiology Foundation, the American Heart Association and the World Heart Federation (Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction) . They are based on revised provisions first set out in the materials of the 2nd international consensus in 2007 (Joint ESC/ACCF/AHA/WHF Task for the Redefinition of Myocardial Infarction, 2007) . Some of the definitions presented in ICD-10 have been retained.

MI is considered acute 28 days old. and less.

Recurrent should be called MI with a recurrence of an ischemic attack more than 3 days later. and less than 28 days. after the previous one.

Repeated MI is recognized when it develops after 28 days. after primary. Both recurrent and repeated MI in ICD-10 have a common code (I22), the fourth character of which depends on the localization of the focus of necrosis.

In accordance with the "Third Universal Definition", "The term acute MI should be used when there is evidence of myocardial necrosis resulting from prolonged acute ischemia." The classification of IM includes 5 types. It is advisable to indicate the types of MI in the diagnosis, although they do not have special codes in the ICD-10 .

Spontaneous MI (MI type 1) is caused by rupture, ulceration, or stratification of an unstable atherosclerotic plaque with the development of intracoronary thrombosis in one or more coronary arteries, leading to a decrease in myocardial perfusion with subsequent necrosis of cardiomyocytes. As already mentioned in the section “acute coronary syndrome”, due to thrombolysis (spontaneous or induced), an intracoronary thrombus may not be detected at autopsy. On the other hand, coronary artery thrombosis can also develop when a stable atherosclerotic plaque is damaged. In addition, type 1 MI can develop with atherocalcinosis of the coronary arteries of the heart, due to plasmorrhagia and fissuring of petrificates, leading to a rapid increase in the degree of arterial stenosis and / or thrombosis.

Type 1 MI is included in the group concept of ACS and is always a nosological form in the composition of IHD, therefore, the diagnosis is indicated under the heading "Main disease" or a competing or combined disease (examples 8 - 11).

• Main disease: Acute transmural myocardial infarction (type 1) anterolateral wall and apex of the left ventricle (about 4 days old, the size of the focus of necrosis). Stenosing atherosclerosis of the coronary arteries of the heart (stenosis up to 50% of the left and unstable, with hemorrhage atherosclerotic plaque of the left descending artery) (I21.0).
• Background disease: Renal arterial hypertension: eccentric myocardial hypertrophy (heart weight 390 g, wall thickness of the left ventricle 2.0 cm, right - 0.3 cm). Chronic bilateral pyelonephritis in remission, pyelonephritic nephrosclerosis (weight of both kidneys - ... g) (I15.1).
• Let's also say: 2. Background disease: Chronic bilateral pyelonephritis in remission, pyelonephritic nephrosclerosis (weight of both kidneys - ... g.). Renal arterial hypertension: eccentric myocardial hypertrophy (heart weight 390 g, wall thickness of the left ventricle 2.0 cm, right - 0.3 cm).
• Complications of the underlying disease: Myomalacia and rupture of the anterior wall of the left ventricle of the heart. Hemotamponade of the pericardium (volume of outflowing blood, ml). Acute general venous plethora. Edema of lungs and brain.
• Accompanying illnesses: peptic ulcer stomach, stage of remission: chronic callous epithelized ulcer (diameter of the ulcer) of the body of the stomach in the region of its lesser curvature. Chronic indurative pancreatitis in remission.

Medical death certificate

I. a) Hemotamponade of the pericardium.

b) Rupture of the anterior wall of the left ventricle of the heart.

c) Acute anteroapical myocardial infarction (I21.0).

II. Renal arterial hypertension (I15.1).

• Main disease: Recurrent large-focal myocardial infarction (type 1) the posterolateral wall of the left ventricle with the transition to the posterior wall of the right ventricle (about 3 days old, the size of the focus of necrosis), macrofocal cardiosclerosis of the lateral wall of the left ventricle (the size of the scar). Eccentric myocardial hypertrophy (heart weight 360 g, wall thickness of the left ventricle 1.7 cm, right - 0.3 cm). Stenosing atherosclerosis of the coronary arteries of the heart (grade 3, stage II, unstable atherosclerotic plaque with hemorrhage of the descending branch of the left artery, stenosis up to 60% of the mouth of the left artery) (I21.2).
• Background disease: Diabetes Type 2, in the stage of decompensation (blood glucose - …, date). Diabetic macro- and microangiopathy: atherosclerosis of the aorta (3rd degree, stage III), cerebral arteries (3rd degree, stage II, stenosis of the arteries of the base of the brain up to 25%), diabetic retinopathy (according to the medical history), diabetic nephrosclerosis (arterial hypertension - clinically) (E11.7).
• Complications of the underlying disease: Acute general venous plethora. Pulmonary edema.

Medical death certificate

I. a) Pulmonary edema.

b) Repeated myocardial infarction, posterolateral with the transition to the right ventricle (I21.2).

• Main disease: Recurrent myocardial infarction (type 1): fresh (about 3 days old - or “from ... date”) and organizing foci of necrosis (about 25 days old) in the region of the posterior wall and posterior papillary muscle of the left ventricle and interventricular septum (size of necrosis foci). Stenosing atherosclerosis of the coronary arteries of the heart (2nd degree, stage II, unstable atherosclerotic plaque with hemorrhage of the left circumflex artery, stenosis of the branches of the left artery up to 60%) (I22.1).
• Background disease: Renovascular hypertension: eccentric myocardial hypertrophy (heart weight 360 g, wall thickness of the left ventricle 1.9 cm, right - 0.2 cm). Stenosing atherosclerosis of the renal arteries (3rd degree, stage III, obturating organized thrombus of the left and stenosis of up to 25% of the right arteries). Primarily wrinkled left kidney (weight 25 g), atheroarteriolosclerotic nephrosclerosis right kidney(I15.0).
• Let's also say: 2. Background disease: Stenosing atherosclerosis of the renal arteries (3rd degree, stage III, obturating organized thrombus of the left and stenosis of up to 25% of the right arteries). Primarily wrinkled left kidney (weight 25 g), atheroarteriolosclerotic nephrosclerosis of the right kidney. Renovascular hypertension: eccentric myocardial hypertrophy (heart weight 360 g, wall thickness of the left ventricle 1.9 cm, right - 0.2 cm).
• Complications of the underlying disease: Avulsion of the posterior papillary muscle of the left ventricle. Cardiogenic shock (clinically), liquid dark blood in the cavities of the heart and the lumen of large vessels. Spot hemorrhages under the pleura and epicardium. Acute general venous plethora. Respiratory distress syndrome.
• Accompanying illnesses: Atherosclerotic dementia (type, another characteristic - clinically), stenosing atherosclerosis of the arteries of the brain (2nd degree, stage II, stenosis predominantly of the left middle cerebral artery up to 50%), moderately pronounced atrophy of the cerebral hemispheres and internal hydrocephalus. Atherosclerosis of the aorta (3rd degree, stage IV).

Medical death certificate

I. a) Cardiogenic shock.

b) Detachment of the posterior papillary muscle of the left ventricle of the heart

c) Recurrent myocardial infarction of the posterior wall and interventricular septum (I22.1).

II. Renovascular arterial hypertension (I15.0).

• Main disease: Ischemic cerebral infarction (atherothrombotic) in the region of the subcortical nuclei of the right hemisphere of the brain (the size of the focus of necrosis). Stenosing atherosclerosis of the arteries of the brain (3rd degree, III stage, stenosis of predominantly anterior and middle left cerebral arteries up to 30%, red obstructive thrombus and unstable atherosclerotic plaque with hemorrhage of the left middle cerebral artery) (I63.3).
• Competing disease:Acute subendocardial myocardial infarction (type 1) the posterior wall of the left ventricle (about 15 days old, the size of the focus of necrosis). Stenosing atherosclerosis of the coronary arteries of the heart (2nd degree, II stage, stenosis up to 50% and unstable, with hemorrhages, atherosclerotic plaques of the circumflex branch of the left coronary artery) (I21.4).
• Background disease: Hypertension: eccentric myocardial hypertrophy (heart weight 430 g, wall thickness of the left ventricle 1.8 cm, right - 0.3 cm), arteriolosclerotic nephrosclerosis (I10).
• Complications of the underlying disease: Bilateral focal pneumonia in the middle and lower lobes of the right lung (etiology). Acute general venous plethora. Edema of lungs and brain.

Medical death certificate

I. a) Focal pneumonia.

b) Ischemic cerebral infarction (I63.3).

II. Acute subendocardial myocardial infarction (I21.4). Hypertension (I10).

MI secondary to ischemic imbalance (MI type 2) develops when a condition other than CAD leads to an imbalance between oxygen demand and/or delivery (endothelial dysfunction, coronary spasm, embolism, tachy/bradyarrhythmias, anemia, respiratory failure, hypotension or hypertension with or without myocardial hypertrophy). Complicated unstable atherosclerotic plaques or atherothrombosis are absent at autopsy.

Type 2 MI in most cases is not a nosological form in the composition of coronary artery disease and in the diagnosis it should be indicated under the heading “Complications of the underlying disease”. The leading role in its pathogenesis (and diagnosis) is comorbidity: the presence, in addition to atherosclerosis of the coronary arteries and coronary artery disease, comorbidities and / or their complications that contribute to the development of ischemic myocardial imbalance. Such combined diseases can be lung diseases, oncological diseases, etc. Even with severe syndrome of chronic cardiovascular insufficiency in a deceased with atherosclerotic or postinfarction cardiosclerosis in IHD, foci of ischemia or myocardial necrosis (in postinfarction cardiosclerosis, usually along the periphery of scars) should be regarded as a complication of the underlying disease, and not repeated MI as part of IHD. Recurrent MI is diagnosed when signs of type 1 MI are detected.

The formulation of the diagnosis is based on the results of clinical and morphological analysis. There are no specific criteria that would allow morphologically to differentiate a small MI in CAD from large focal myocardial necrosis of hypoxic and mixed genesis, which can develop in patients, for example, with severe anemia and the presence of atherosclerosis (but not atherothrombosis, as in type 1 MI) coronary arteries of the heart. In such observations, in the pathoanatomical diagnosis under the heading “Complications of the underlying disease”, it is more appropriate to use the term MI type 2, and not “myocardial necrosis”, although non-coronary hypoxic factor plays an important role in its pathogenesis (examples 12, 13).

• Main disease: COPD: chronic obstructive purulent bronchitis in the acute stage. Focal pneumonia in III-IX segments of both lungs (etiology). Diffuse mesh pneumosclerosis, chronic obstructive pulmonary emphysema. Secondary pulmonary hypertension. Cor pulmonale (wall thickness of the right ventricle of the heart - 0.5 cm, FI - 0.8) (J44.0).
• Combined disease: Large-focal cardiosclerosis of the posterior wall of the left ventricle. Stenosing atherosclerosis of the coronary arteries of the heart (2nd degree, stage II, stenosis predominantly of the left circumflex artery up to 40%) (I25.8).
• Background disease: Hypertension: eccentric myocardial hypertrophy (heart weight 390 g, left ventricular wall thickness 1.7 cm), arteriolosclerotic nephrosclerosis (I10).
• Complications of the underlying disease: Acute general venous plethora. Myocardial infarction type 2 in the region of the posterior wall of the left ventricle and the apex of the heart. Brown induration of the lungs, nutmeg liver, cyanotic induration of the kidneys, spleen. Edema of lungs and brain.

Medical death certificate

b) COPD in the acute stage with bronchopneumonia (J44.0).

II. Large focal cardiosclerosis (I25.8)

Hypertension (I10).

• Main disease: Large-focal cardiosclerosis of the posterior wall of the left ventricle. Stenosing atherosclerosis of the coronary arteries of the heart (2nd degree, stage II, stenosis predominantly of the left circumflex artery up to 40%) (I25.8).
• Background disease:
• Complications of the underlying disease: Chronic general venous plethora: brown induration of the lungs, nutmeg liver, cyanotic induration of the kidneys, spleen. Subendocardial foci of myocardial necrosis (myocardial infarction type 2) in the posterior wall of the left ventricle. Edema of lungs and brain.

Medical death certificate

I. a) Chronic cardiovascular insufficiency

b) Large focal cardiosclerosis (I25.8)

II. Hypertension (I10).

In rare cases, type 2 MI can be qualified as a form of coronary artery disease and put under the heading "Main disease" in the absence of any diseases and their complications that cause hypoxic or metabolic damage to the myocardium (lack of comorbidity) and the presence of atherosclerosis of the coronary arteries of the heart with stenosis of their clearance by more than 50%. Such an example is a circular subendocardial MI that developed with atherosclerotic lesions of 2 or 3 coronary arteries of the heart without complicated plaque or atherothrombosis (Example 14).

• Main disease: Acute myocardial infarction (type 2) posterolateral wall of the left ventricle with a transition to the posterior wall of the right ventricle (about 2 days old, the size of the focus of necrosis), Stenosing atherosclerosis of the coronary arteries of the heart (3rd degree, stage III, stenosis predominantly of the left circumflex artery up to 70%) (I21. 2).
• Background disease: Hypertension: eccentric myocardial hypertrophy (heart weight 390 g, wall thickness of the left ventricle 1.7 cm, right 0.2 cm), arteriolosclerotic nephrosclerosis (I10).
• Complications of the underlying disease: Acute common venous congestion. Edema of lungs and brain.

Medical death certificate

I. a) Acute cardiovascular failure

b) Acute myocardial infarction, posterolateral with transition to the right ventricle (I21.2).

II. Hypertension (I10).

Type 3 MI (MI resulting in death when CV biomarkers are not available) is cardiac death with symptoms suggestive of myocardial ischemia and presumably new ischemic ECG changes or new left bundle branch block, if death occurred before blood sampling or before the level of cardiospecific biomarkers should rise, or in those rare situations where they are not explored.

Type 3 MI is a clinical concept. At autopsy, acute coronary death, type 1 or 2 MI, as well as other coronarogenic or non-coronary myocardial necrosis of various pathogenesis can be diagnosed. Depending on this, this type of myocardial necrosis can appear in various headings of the diagnosis.

Type 4 MI, a is percutaneous coronary intervention (PCI)-associated MI or PCI-associated MI.

Type 4b MI is MI associated with coronary artery stent thrombosis..

Type 5 MI is MI associated with coronary artery bypass surgery (CABG) or CABG-associated MI.

MI types 4 a, 4 b and 5 are nosological forms in the composition of IHD, develop as a complication of various types of percutaneous coronary interventions or CABG performed for atherosclerotic lesions of the coronary arteries of the heart in patients with IHD. In the diagnosis, these types of MI are indicated as the underlying disease, and changes in the coronary arteries of the heart and the type of intervention are indicated as its manifestation, if there are no reasons to formulate a diagnosis as in iatrogenic pathology.

Thus, in the final clinical, pathoanatomical or forensic diagnosis, MI can be presented as the main disease (or as a competing or combined disease), only if it is qualified as a nosological form from the CHD group. All other types of myocardial necrosis (including, apparently, the majority of type 2 MI) are a manifestation or complication of various diseases, injuries or pathological conditions.

Myocardial necrosis is a heterogeneous group of focal irreversible myocardial damage in terms of etiology, pathogenesis and morphogenesis, as well as in terms of the extent of the lesion, clinical manifestations and prognosis. From the standpoint of general pathology, myocardial necrosis is usually divided into coronarogenic (ischemic, or MI [the term "MI" is not equivalent to its nosological form in the composition of IHD]) and non-coronary (hypoxic, metabolic, etc.). According to clinical criteria, in accordance with the Third International Consensus, myocardial damage (mainly non-coronary) and MI are distinguished. In connection with the introduction into clinical practice of highly sensitive tests for determining the blood level of cardiospecific biomarkers (especially cardiac troponin I or T), it must be taken into account that they can increase with minimal coronary and non-coronary myocardial damage (Table 1).

Table 1

Myocardial injury accompanied by an increase in cardiac troponin levels

Damage caused by primary myocardial ischemia

Rupture of unstable atherosclerotic plaque of the coronary artery of the heart

Intracoronary thrombosis

Damage secondary to ischemic imbalance in the myocardium

Tachy/bradyarrhythmias

Dissecting aneurysm, ruptured aortic aneurysm, or severe aortic valve disease

Hypertrophic cardiomyopathy

Cardiogenic, hypovolemic, or septic shock

severe respiratory failure

severe anemia

Arterial hypertension with or without myocardial hypertrophy

Spasm of the coronary arteries

Thromboembolism of the coronary arteries of the heart or coronary disease

Endothelial dysfunction with lesions of the coronary arteries of the heart without hemodynamically significant stenosis

Lesions not associated with myocardial ischemia

Myocardial contusion, cardiac surgery, radiofrequency ablation, pacing and defibrillation

Rhabdomyolysis with myocardial involvement

Myocarditis

Effects of cardiotoxic drugs (eg, anthracyclines, herceptin)

Multifactorial or unexplained myocardial injury

Heart failure

Stress cardiomyopathy (takotsubo)

Massive PE or severe pulmonary hypertension

Sepsis and the terminal state of the patient

kidney failure

Severe neurological pathology (stroke, subarachnoid hemorrhage)

Infiltrative diseases (eg, amyloidosis, sarcoidosis)

Physical overvoltage

The pathogenesis of myocardial necrosis is often mixed; therefore, the allocation of their coronarogenic and non-coronary types is often rather conditional. For example, the pathogenesis of myocardial necrosis in diabetes mellitus is associated with both ischemic and microcirculatory disorders, metabolic, hypoxic and neurogenic factors.

Coronary (ischemic) myocardial necrosis develop as a result of impaired blood supply to the myocardium associated with damage to the coronary arteries of the heart. The main reasons for the development of ischemic necrosis, not included in the IHD group, are as follows:

• - (thrombo)vasculitis (coronitis) and sclerosis of the coronary arteries (rheumatic diseases, systemic vasculitis, infectious and allergic diseases etc.);
• - vasculopathy - thickening of the intima and media of the coronary arteries with metabolic disorders, proliferation of their intima (homocysteinuria, Hurler syndrome, Fabry disease, amyloidosis, juvenile arterial calcification, etc.);
• - myocarditis of various etiologies;
• - thromboembolism of the coronary arteries (with endocarditis, thrombi of the left heart, paradoxical thromboembolism);
• - traumatic injuries of the heart and its vessels;
• - primary tumor of the heart or metastases of other tumors in the myocardium (tissue embolism);
• - congenital malformations of the heart and coronary arteries of the heart, non-atherosclerotic aneurysms with thrombosis or rupture;
• - systemic diseases with the development of narrowing of the coronary arteries various genesis, but not atherosclerotic in nature;
• - imbalances between myocardial oxygen demand and its supply (aortic stenosis, aortic insufficiency, thyrotoxicosis, etc.);
• - congenital and acquired coagulopathy with hypercoagulation (thrombosis and thromboembolism: DIC, paraneoplastic syndrome, antiphospholipid syndrome, erythremia, thrombocytosis, blood clotting, etc.);
• - violation of the structural geometry of the heart with a local pronounced decrease in coronary blood flow in cardiomyopathies, myocardial hypertrophy of any origin,
• - drug use (eg cocaine-associated MI, etc.).

In particular, congenital aneurysm of the coronary artery of the heart with rupture (code Q24.5 according to ICD-10) and the development of cardiac hemotamponade should not be attributed to diseases from the group of coronary artery disease. In the diagnosis, both the use of the term "IM", which is more consistent with their general pathological nature, and "myocardial necrosis" are allowed (examples 15, 16).

• Main disease: Ulcerated subtotal gastric cancer with extensive tumor decay (biopsy - moderately differentiated adenocarcinoma, no., date). Cancer metastases to perigastric lymph nodes, liver, lungs (T4N1M1). C16.8
• Complications of the underlying disease: Paraneoplastic syndrome (hypercoagulation syndrome ...). Obturating red thrombus ... of the coronary artery. myocardial infarction anterior wall of the left ventricle.
• Accompanying illnesses: Chronic calculous cholecystitis, stage of remission

Medical death certificate

I. a) Myocardial infarction

b) Paraneoplastic syndrome

c) Subtotal gastric cancer (adenocarcinoma) with metastases, T4N1M1 (C16.8)

• Main disease: Polyarteritis nodosa (periarteritis) with a primary lesion of the coronary arteries of the heart, mesenteric arteries, .... (M.30.0)
• Complications of the underlying disease: myocardial infarction in the region of the posterior and lateral walls of the left ventricle, ....

Medical death certificate

I. a) Myocardial infarction

b) Polyarteritis nodosa (M30.0)

Non-coronary necrosis develop while maintaining coronary blood flow due to:

• - hypoxia (absolute or relative, with increased myocardial oxygen demand), characteristic of many diseases and their complications,
• - exposure to cardiotropic toxic substances, both exogenous, including medicines(cardiac glycosides, tricyclic antidepressants, antibiotics, cytostatics, glycocorticoids, chemotherapy drugs, etc.), and endogenous,
• - a variety of metabolic and electrolyte disorders (with metabolic pathology, organ failure, etc.),
• dishormonal disorders (diabetes mellitus, hypo- and hyperthyroidism, hyperparathyroidism, acromegaly),
• - neurogenic disorders, for example, in cerebrocardial syndrome in patients with severe brain damage (ischemic infarcts, traumatic and non-traumatic hematomas), which are also characterized by impaired blood supply to the myocardium (coronary, ischemic component),
• - infectious-inflammatory and immune (autoimmune, immunocomplex) lesions of the myocardium and often the vessels of the heart, i.e. with coronarogenic, ischemic component ( infectious diseases, sepsis, rheumatic and autoimmune diseases, myocarditis).

Relative hypoxia occurs when various arrhythmias, myocardial hypertrophy, arterial hypo- and hypertension, pulmonary hypertension, heart defects, as well as many other conditions, including surgery and trauma. Non-coronary myocardial necrosis can be observed in cardiomyopathies, severe diseases with cardiac, renal, hepatic, pulmonary or multiple organ failure, severe anemia, sepsis and shock of any genesis, as well as in postoperative period, terminal state and in resuscitation illness (examples 17-23).

• Main disease: Alcoholic subtotal mixed pancreatic necrosis. The operation of laparotomy, sanitation and drainage of the omental bag and abdominal cavity(date) (K85).
• Background disease: Chronic alcohol intoxication with multiple organ manifestations: alcoholic cardiomyopathy, alcoholic encephalopathy, polyneuropathy, fatty hepatosis (F10.2).
• Complications of the underlying disease: Pancreatogenic (enzymatic) shock. Myocardial necrosis in the area of ​​the anterior and lateral walls of the left ventricle. Respiratory distress syndrome. Necrotic nephrosis. Cerebral edema.
• Accompanying illnesses: Large-focal cardiosclerosis of the posterior wall of the left ventricle. Stenosing atherosclerosis of the coronary arteries of the heart (2nd degree, stage II, stenosis predominantly of the left circumflex artery up to 40%).

Medical death certificate

I. a) Pancreatogenic shock

b) Alcoholic pancreatic necrosis (K85)

II. Chronic alcohol intoxication (F10.2)

Operation of laparotomy, sanitation and drainage of the omental sac and abdominal cavity (date).

• Main disease: Nodular-branched cancer of the upper lobe bronchus of the left lung with massive tumor decay (... - histologically). Multiple cancer metastases to ... lymph nodes, bones (...), liver, ... (T4N1M1) (C34.1).
• Background disease: COPD in the acute stage: (c) Chronic obstructive purulent bronchitis. Diffuse mesh and peribronchial pneumosclerosis. Chronic obstructive pulmonary emphysema. Focal pneumonia in ... segments of both lungs (etiology). Foci of dysplasia and metaplasia of the bronchial epithelium (histologically) (J44.0).
• Complications of the underlying disease: Secondary pulmonary hypertension, cor pulmonale (heart weight - ... g, right ventricular wall thickness - ... see, ventricular index - ...). Acute general venous plethora. Pleural empyema on the left. Foci of myocardial necrosis in the region of the apex of the heart and the posterior wall of the left ventricle. Pulmonary edema. Cerebral edema.
• Accompanying illnesses:

Medical death certificate

I. a) Foci of myocardial necrosis

b) Pleural empyema

c) Cancer of the left upper lobe bronchus with widespread metastases (T4N1M1) (C34.1).

II. COPD in the acute stage with bronchopneumonia (J44.0).

• Main disease: Cancer of the left breast (... - histologically). Metastases to ... lymph nodes, lungs, liver. Radiation and chemotherapy (….) (T4N1M1) (C50.8).
• Associated disease: Chronic bilateral pyelonephritis in the acute stage .... (N10).
• Background disease: Type 2 diabetes mellitus, decompensated (blood biochemistry - ..., date). Atrophy and lipomatosis of the pancreas. Diabetic macro- and microangiopathy (…).
• Complications of the underlying disease: Acute general venous plethora. Focal confluent pneumonia in ... segments of the left lung (etiology). Foci of myocardial necrosis in the region of the apex of the heart. Pulmonary edema.
• Accompanying illnesses: Large-focal cardiosclerosis of the posterior wall of the left ventricle. Stenosing atherosclerosis of the coronary arteries of the heart (2nd degree, stage II, stenosis predominantly of the left circumflex artery up to 50%).

Medical death certificate

I. a) Foci of myocardial necrosis

b) Focal pneumonia

c) Cancer of the left breast with widespread metastases (T4N1M1) (C50.8).

II. Chronic bilateral pyelonephritis in the acute stage (N10)

• Main disease: Hypertension with a primary lesion of the heart and kidneys. Eccentric myocardial hypertrophy (heart weight 510 g, wall thickness of the left ventricle 2.2 cm, right - 0.4 cm) with severe dilatation of the heart cavities. Non-stenosing atherosclerosis of the coronary arteries of the heart (grade 1, stage II). Arteriolosclerotic nephrosclerosis with outcome in primary contracted kidneys (weight of both kidneys 160 g) (I13.1).
• Complications of the underlying disease: CRF, uremia (blood biochemistry -…, date): uremic erosive and ulcerative pangastritis, fibrinous enterocolitis, fibrinous pericarditis, fatty degeneration of the liver. Chronic general venous plethora. Foci of myocardial necrosis in the anterior and posterior walls of the left ventricle (dimensions). Edema of lungs and brain.
• Accompanying illnesses: Atherosclerosis of the aorta, arteries of the brain (2nd degree, II stage).

Medical death certificate

I. a) Uremia.

b) Hypertension with damage to the heart and kidneys (I13.1).

• Main disease: Cancer of the floor of the mouth (... - histologically). Cancer metastases to cervical and submandibular lymph nodes on both sides (T4N1M0) (C04.8).
• Complications of the underlying disease: Metastasis necrosis in the left submandibular lymph node with arrosia ... arteries. Massive arrosive bleeding. Operation to stop bleeding (date). Hemorrhagic shock (...). Acute posthemorrhagic anemia (data clinical analyzes). Acute general anemia internal organs. Foci of myocardial necrosis in the posterior wall of the left ventricle. Respiratory distress syndrome. Necrotic nephrosis.
• Accompanying illnesses: Diffuse small focal cardiosclerosis. Stenosing atherosclerosis of the coronary arteries of the heart (2nd degree, stage II, stenosis mainly of the branches of the left artery up to 50%). Atherosclerosis of the aorta (3rd degree, stage IV).

Medical death certificate

I. a) Hemorrhagic shock

b) Necrosis of metastasis in the lymph node with arterial erosion and

bleeding.

c) Cancer of the floor of the mouth with metastases (T4N1M0) (C04.8).

• Main disease: Phlegmon of the upper and middle third of the thigh (L03.1).
• Background disease: Diabetes mellitus type 2, decompensation stage (blood biochemistry - ..., date). Atrophy, sclerosis and lipomatosis of the pancreas. Diabetic macro- and microangiopathy, retinopathy, polyneuropathy, diabetic nephrosclerosis. E11.7
• Complications of the underlying disease: Sepsis (bacteriologically - ..., date), septicemia, septic shock: systemic inflammatory response syndrome (indicators ...). Hyperplasia of the spleen (mass ...). Syndrome of multiple organ failure (indicators ...). Respiratory distress syndrome. Necrotic nephrosis. DIC syndrome. Myocardial necrosis posterior and lateral walls of the left ventricle.

Medical death certificate

I. a) Sepsis, septic shock

b) Phlegmon of the upper and middle third of the thigh (L03.1)

II. Type 2 diabetes mellitus (E11.7)

• Main disease: Acute phlegmonous perforative calculous cholecystitis. Operation of laparotomy, cholecystectomy, sanitation and drainage of the abdominal cavity (date) (K80.0).
• Complications of the underlying disease: Hepatic and renal insufficiency, electrolyte disturbances (indicators - according to clinical data). Foci of myocardial necrosis in the region of the posterior and lateral walls of the left ventricle.
• Accompanying illnesses: Large-focal cardiosclerosis of the posterior wall of the left ventricle. Stenosing atherosclerosis of the coronary arteries of the heart (2nd degree, stage II, stenosis predominantly of the left circumflex artery up to 40%). Hypertension: concentric myocardial hypertrophy (heart weight 390 g, wall thickness of the left ventricle 1.7 cm, right 0.2 cm), arteriolosclerotic nephrosclerosis (I10). Atherosclerosis of the aorta (3rd degree, stage IV).

Medical death certificate

I. a) Foci of myocardial necrosis

b) Hepato-renal insufficiency

c) Acute phlegmonous perforative calculous cholecystitis (K80.0)

II. Operation of laparotomy, cholecystectomy, sanitation and drainage of the abdominal cavity (date)

With the development of myocardial necrosis in the first 4 weeks after surgery and the absence of complicated unstable atherosclerotic plaques in the coronary arteries of the heart (atherothrombosis), they should be regarded as a complication and indicated under the heading “Complications of the underlying disease”. The exception is the detection morphological features MI type 1.

Thus, the only specific morphological diagnostic criterion MI as a nosological form in the composition of IHD is a complicated, mainly unstable atherosclerotic plaque of the coronary artery of the heart. In other cases, the qualification of myocardial necrosis should be the result of clinical and morphological analysis.

In the differential diagnosis of coronarogenic and non-coronary necrosis with MI as a nosological form in the composition of IHD, the following clinical and morphological criteria should be taken into account :

• - anamnestic and clinical and laboratory data (if available, and a history of coronary artery disease and / or a slight increase in the level of cardiac troponin cannot be diagnostic criteria for MI from the IHD group);
• - the presence of diseases and their complications that may be the cause of the development of certain types of myocardial necrosis (comorbidity is more typical for type 2 MI);
• - changes in the coronary and intramural arteries of the heart (but the presence of stenosing atherosclerosis without complicated atherosclerotic plaque or atherothrombosis cannot be a criterion for diagnosing MI from the IHD group);
• - morphological (macro- and microscopic) features of the heart and its valvular apparatus (changes in the structural geometry of the heart, valve damage, etc.);
• - the number, size, localization and histological features of necrosis foci (non-coronary myocardial necrosis is usually multiple, small in size, located simultaneously in the blood supply pools of different arteries, sometimes with specific changes characteristic of the underlying disease or not corresponding in morphology to the terms of necrosis);
• - morphological features of the myocardium outside the zone of necrosis (changes in cardiomyocytes - fatty degeneration, etc., stroma - inflammatory infiltration etc., vessels - vasculitis, vasculopathy, etc., often characteristic of the underlying disease).

Literature

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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 diseases of the heart, circulatory system, and 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 points 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.