IBS Treatment with the latest generation. Nitrates against IBS

Treatment of ischemic heart disease implies a wide range of various measures, part of which is drug therapy. Cultivities are treated for special principles that imply actions in several directions. With IHD, many drugs are used, each group of which is necessary to achieve a specific goal.

General Principles of Drug Treatment of IBS

During drug treatment of ischemic heart disease, it is necessary to use a complex approach. This allows you to achieve results at once in several directions.

Drug therapy IBS is based on the following principles:

• saving manifestations of the already developed illness;
• preventing disease progression;
• carrying out the prevention of complications;
• normalization of lipid metabolism;
• normalization of blood coagulation;
• improving myocardial state;
• normalization of pressure;
• increased tolerance to physical exertion;
• accounting for the form of the disease and the patient's reaction to the preparations of the same group;
• accounting for developing complications: usually refers to the insufficiency of blood circulation;
• accounting for concomitant diseases: more often it applies to sugar diabetes, system atherosclerosis.

The approach to medication treatment of each patient should be individual. When prescribing drugs, it is necessary to take into account many factors, including the nuances of the disease and individual characteristics patient.

Statins

This group of drugs is cholesterizing. The inclusion of them in the treatment of IBS is necessary, since, thanks to them, atherosclerotic plaques are developing slower, reduced in size, and new ones are no longer formed.

The use of statins has a positive effect on the life expectancy of the patient, frequency and severity of cardiovascular seizures. Such preparations make it possible to achieve the target level of cholesterol of 4.5 mmol / l, and it is necessary to reduce the level of low-density lipoproteins to 2.5 mmol / l.

The effectiveness of statins is due to their interaction with the liver, where the production of the enzyme required for the production of cholesterol is depressed. With a decrease in the total level of cholesterol, its direct and reverse transport comes to normal.

The CHD usually resort to the following preparations from the Statin Group:

• Atorvastatin;
• Lovastatin;
• Rosavastatin;
• Simvastatin.

In the treatment of ischemic heart disease, statins are usually prescribed in high dosage. For example, Rosavastin is taken by 40 mg, and atorvastatin - 80 mg.

Antiagreganta

Such drugs are necessary to prevent thrombosis. Under the action of these medicines, the aggregation of platelets and erythrocytes is inhibited. As a result, their ability to glue and adhesive to the vascular endothelium decreases.

Due to the reduction in surface tension, the erythrocyte membranes decreases their damage during the passage through the capillaries. As a result, blood flow is improved.

Acetylsalicylic acid is often used in the treatment of IHD, which underlies aspirin, aceback, thrombollane. Take these drugs one time per day in a dosage of at least 75 mg.

Another effective antiagregant is clopidogrel. There are preparations such as Plavix, Clopidogrel on this substance. Accept it also once a day at 75 mg.

Antiagregants provide not only the prevention of aggregation, but also are able to disaggregate aggregated platelets.

Antagonists of Renin-angiotensin-aldosterone system (ACE inhibitors)

Preparations of this group affect the angiotensin-glossing enzyme, running a whole chain of reactions. The bradykinin decay slows down, the post-load and the production of angiotensin II decreases, which narrows the vessels.

Thereby aPF inhibitors Provide several actions at once:

• hypotensive;
• nephroprotective;
• cardioprotective.

The use of ACE inhibitors for ischemic heart disease allows to achieve targeted testimony arterial pressure. When choosing a suitable drug based on the ability of the active substance to penetration into tissue. In the treatment of IBS, they choose the means to be used once a day. At the same time, it should be excluded in different ways to allow treatment against the background of renal or liver failure.

From among the inhibitors of ACE, often resort to captoprot and. Only such drugs provide direct effect when the remaining representatives of this group are prodrugs. The latter refer to which also often include IBS treatment.

ACE inhibitors are prescribed with myocardial infarction, especially in the first hours of its development. In this case, the instability of hemodynamics is observed, because the risk of development or aggravation increases. In such a situation, drugs include a minimum dosage treatment, which is increased only after stabilizing hemodynamics under pressure control.

Blockers receptor angiotensin

Preparations of this group are usually prescribed with IHD in the case when ACE inhibitors cannot be applied due to the individual intolerance to the patient. These medicines block angiotensin II receptors and are known under a different name - sartans or angiotensin receptor antagonists.

The main purpose of angiotensin receptor blockers is a hypotensive effect. A single reception of the drug ensures its effectiveness during the day. In addition to the antihypertensive effect, medicines of this group have a positive effect on lipid metabolism, reducing low density lipoproteins and triglycerides.

Another important quality of angiotensin receptor antagonists - reducing the number uric acid in blood. This factor is important when long-term diuretic therapy was prescribed to the patient.

One of the most effective Sartan is Valsartan. This is the only drug of this group that can be used after myocardial infarction.

The advantage of Sartan is in minimal risk side Effects. This is especially true of dry cough, which often arises against the background of receiving ACE inhibitors.

Beta adrenoblocators

Preparations of this group affect β-adrenoreceptors. As a result, the heart rate is reduced, which reduces the need for the heart muscle in oxygen.

The inclusion of β-adrenobloclars has a positive effect on the duration of the patient's life, and also reduces the probability of the frequency of cardiovascular events, including recurrent.

β-adrenoblays are one of the main directions in the treatment of ischemic heart disease. They allow you to get rid of angina, improve the quality of life and forecast after myocardial infarction and in chronic heart failure.

When angina, the treatment starts with a minimum dosage, adjusting it if necessary. In the case of side effects of the drug can be canceled.

In the treatment of IBS, it is usually resorted to, Carvedilol, metoprolol. If the selected β-adrenoblocator is inffective or an increase in its dosage is impossible, it is combined with a nitrate or calcium antagonist. In some cases, a combination of all three means is required. An antiagonal agent can be appointed additionally.

Nitrate

This group is represented by derivatives of glycerol, diglycerides, monoglycerides and triglycerides. As a result of the impact of nitrates, the contractile activity of the smooth muscles of vessels changes, the preload on myocardium is reduced. This is ensured by the expansion of vessels in the venous bed and blood deposit.

The use of nitrates causes pressure drop. Such preparations are not prescribed if the pressure is not higher than 100/60 mm Hg. Art.

With IHS, nitrates are mainly used to. Increased survival on the background of such treatment is not observed.

At high pressure, the attacks are bought by intravenous drip administration of the drug. There is also a tablet and inhaled form.

From the number of nitrates in the treatment of ischemic heart disease, they usually resort to nitroglycerin or isosorbide mononitut. The patient is recommended to constantly have a prescribed drug with him. It is worth it under the attack of angina in the event that the exclusion of the provoking factor does not help. Repeating nitroglycerin is allowed, but in the absence of the effect after that it should be called ambulance.

Cardiac glycosides

With IHD into drug therapy, various antiarrhythmic drugs include one of the groups of which are cardiac glycosides. Their distinctive feature - plant origin.

The main purpose of heart glycosides is the treatment of heart failure. Reception of such a drug leads to improving myocardial performance, improving its blood supply. The cardiac frequency is reduced, but their strength increases.

Cardiac glycosides are able to normalize arterial and lower venous pressure. Prescribe such drugs with ischemic heart disease infrequently due to high risk adverse Reactions.

From among heart glycosides, they are more often resorted to digoxin or korglikon. The first drug is based on a woolly against the second, the second on May Lrangee.

Calcium antagonists

Preparations of this group block calcium channels (L-type). Due to the penetration of calcium ion penetration, their concentration in cardiomyocytes and smooth vascular muscles are reduced. This ensures the expansion of coronary and peripheral arteries, therefore there is a pronounced vasoid effect.

The main purpose of the block plants of slow calcium channels with IHD is the prevention of angina attacks. Antianginal properties of this dosage group resemble the properties of beta-adrenoblocators. Such drugs also reduce the heart rate, provide an antiarrhythmic effect and the oppression of the reduction of the heart muscle.

For IBS blocters Slow calcium channels are usually used if the increased pressure is combined with a stable angina, as well as for the prevention of ischemia with patients having a vasospadic angina.

The advantage of calcium antagonists in front of β-adrenoblockers consists in the possibility of applying people from a wide range of people, as well as use in the case of contraindications or individual intolerance of beta-adrenobloclars.

From among the calcium antagonists in the treatment of IBS, usually resort to verapamil, nifedipine, diltiasis, amlodipine, felodipine.

Diuretics

Preparations of this group are diuretic. When they are used, the removal with urine and salts increases, the rate of formation of urine increases. This leads to a decrease in the amount of fluid in the tissues.

Such an action allows you to apply diuretics in order to reduce pressure, as well as at edema on the background of cardiovascular pathologies.

With IHD, a thiazide or loop row diuretics are used. In the first case, drugs are potassium-saving. Systematic therapy with medicines of this group ensures a decrease in the risk of complications affecting the cardiovascular system against the background of hypertension. From among thiazide diuretics, they are often resorted to indapamide or hypothiazid. Such drugs are intended for long-term treatment - necessary therapeutic effect It is achieved after the month of continuous reception.

Loop diuretics provide a fast and expressed result. They usually serve as an ambulance and help to carry out forced diuresis. From this group usually use furosemide. It has a tablet and injecting form - the appropriate option is selected by circumstances.

Antihypoxants

Currently, such drugs are quite rare. Under their effect, the oxygen utilization is improved, which circulates in the body. As a result, the resistance to oxygen starvation increases.

One of the effective drugs from the number of antihypoxants - Actovegin. Its action consists in activating glucose and oxygen metabolism. The medication also provides an antioxidant effect. Actovegin is used in high doses when acute infarction Myocardial, as it ensures the prevention of reperfusion syndrome. A similar effect is necessary when the patient has chronic heart failure, thrombolytic therapy or balloon angioplasty passed.

Another effective antihypoxant is hypoxen. When taking such a drug, the tolerance of hypoxia increases, since mitochondria begin to consume oxygen faster, and the conjugacy of oxidative phosphorylation increases. This drug is suitable for any kinds of oxygen starvation.

It is also used by cytochrome C. This enzyme tool catalyzes cellular breathing. The preparation contains iron, which turns into a reducing form and accelerating oxidative processes. The disadvantage of the drug consists in the risk of allergic reactions.

Hypoxants include trimetazidine. This antianginal medication does not apply to standard diagrams in the treatment of ischemic heart disease, but can be used as an additional fund. Its action lies in the normalization of energy cellular metabolism against the background of hypoxia and ischemia. In drug treatment with IHD, this drug is included as the prevention of angina attacks. It is also shown to patients with dizziness and noise in the ears against the background of impaired cerebral circulation.

Anticoagulants

Medicines of this group affect the rolling system of blood, coal activity. As a result, the drug impedes thrombosis.

UHA is usually resorted to heparin, which is an anticoagulant direct action. The anticoagulant activity of the medication is ensured by activation of antithrombin III. Due to certain reactions, which are provided by heparin, antithrombin III becomes capable of inactivating coagulation factors, kallicrein, serine proteases.

With ischemic heart disease, the drug can be introduced subcutaneously (abdominal area) or intravenously by means of infusomat. With myocardial infarction, this drug is prescribed to prevent thrombus formation. In this case, resort to subcutaneous administration Funds in the amount of 12,500 meters. Such a procedure is repeated every day during the week. If the patient is in the resuscitation department and intensive therapy, then heparin is introduced infusomat.

Warfarin is also used at IHD. This drug is an anticoagulant of indirect action. It is usually prescribed if a permanent form is diagnosed in the patient clear arrhythmia. The dosage of the medicine is selected in such a way that blood clotting kept at level 2-3.

Warfarin provides active dissolution of thrombones, but is able to lead to bleeding. Such a drug can only be used when prescribed by a doctor. Be sure to control blood tests during treatment.

Antithromobocytes

Antithrombotic therapy for ischemic heart disease is prescribed both in acute and in the chronic course. Preparations of this group allow you to inhibit platelet functions. They affect the hemochaguance system, restore the vessel's passability against the background of their thrombolysis.

One of the effective antitrombocytes is dipyridamol, which is a pyrimidoid-pyrimidine derivative. It is inherent in vazodilative and antitrombocyte properties. Usually this drug is prescribed to take twice a day. Against the background of coronary heart disease, medication combines aspirin with small doses.

The main representatives of the antitroscopy are aspirin and clopidogrel. Against the background, aspirin is prescribed, and if there are contraindications to it, they are resorted to the second option.

Non-steroidal anti-inflammatory means

Non-steroidal anti-inflammatory means are distinguished by a wide range of applications and a complex action. These drugs have painful, anti-inflammatory and antipyretic properties.

The advantage of non-steroidal anti-inflammatory medicines is high security and low toxicity. The risk of complications of low even when taking high doses of such drugs.

The effect of non-steroidal anti-inflammatory drugs is due to the blocking of the formation of prostaglandins. Precisely because of these substances inflammation develops, pain, fever, muscle spasms.

Anti-inflammatory non-steroidal means reduce vessel permeability, increase microcirculation in them.

One of the most famous drugs of this group is aspirin. With ischemic heart disease, a life receipt of this medicine is appointed to the patient if there are no contraindications to such treatment.

The well-known representatives of non-steroidal anti-inflammatory group are diclofenac and ibuprofen. The use of such drugs with myocardial infarction is not recommended, as it is negatively reflected on the forecast. Similar to the approach and with equivalent infarction of states.

Medicase therapy for coronary heart disease implies the use of a whole complex of drugs. Each of them provides a certain result. A competent combination of different medicines for a particular patient must be determined individually. Make it can only specialist.

Enough serious disease And it is necessary to approach his treatment with all seriousness. Only the integrated purpose of the necessary drugs can bring the desired results. It is also necessary to remember that only an experienced good cardiologist is capable of designating suitable therapy. It is not possible to cope with a similar task independently, since it is necessary to take into account not only the individual features of the course of the disease, but also the compatibility of drugs among themselves so that one of them does not neutralize the effect of another or the more so did not provoke the patient's deterioration on the contrary. For this, the main remedy is selected from each drug group that will neutralize the disease completely.

It is very important to also pay attention to the causes of the disease - the selection of drugs should be carried out precisely with these features.

Ischemia is a complex disease that requires an integrated approach to treatment. Some tablets do not cope here - it is important to change the lifestyle, reconsider the habits.

Only when complying with the required mode in the complex with the reception of the necessary drugs, you can achieve the desired result.

It is also clearly understood that even if the course of treatment will bring excellent results and the disease will no longer make it felt, it still does not mean that no longer needs to take care of your health. In case of impact on the body of provoking factors, the recurrence of the development of pathology is very high. Under all the recommendations of the attending physician, the likelihood of the fact that the disease does not return will not return anymore. But then it is very important to pay attention to the reception of drugs that contribute to maintaining the heart of the heart.

Selection of therapy

First of all, it is necessary to take into account the fact that therapy should be selected on the basis of the following factors:

• the causes of the occurrence of IBS;
• the purpose of therapy. Therapy can be supportive (after the main course of treatment and stabilization of the state), to remove an acute attack, recovery after surgical intervention etc.;
• accompanying illnesses;
• as far as the launched disease, the features of its flow, at what stage.

Of course, the individual characteristics of the patient's body should be taken into account. It may have allergies to some designated drugs, possess individual intolerance. All this is very important to know a doctor before drawing up a list of recommendations in the reception of the necessary drugs.

Additional measures

In addition to receiving medicines, it is very important to eliminate the impact of absolutely all provoking factors:

• reduced arterial pressure. And IHS - often not only complement each other, but also separately provoke complications. To prevent it very important to keep track of your arterial pressure, not allowing not only its smooth and stable increases, but also sharp jumps. It is also important to control your diet. It is obesity that largely provokes an increase in blood pressure, therefore it is worth abandoning fatty foods (especially animal fats), as well as rapidly digestible carbohydrates;
• control over cholesterol in the blood. To do this, it is necessary to minimize the consumption of sour cream, butter and chicken eggs;
• reducing the amount of fluid consumed. Overhabitable liquid use contributes to the formation of various edema, which should be avoided in this case. When accumulating a large amount of fluid in the body increases blood volume, which significantly increases the load on the heart;
• refusal of smoking and abuse of alcoholic beverages;
• normalization of sugar. To do this, it is necessary to reduce the consumption of sweet food;
• elimination of other provoking factors, namely the control of their lifestyle. For example, it is necessary physical activity in the life of such people, but at the same time physical exertion should be moderate, do not cause pain and other unpleasant sensations. Ideal for this, swimming or hiking on the fresh air. This will simultaneously help solve several tasks: contributes to the discharge of blood, prevents the occurrence of edema, as well as obesity.

Aqua aerobica occupation

If these simple recommendations are not followed, even at the completion of a qualitative and effective course of treatment, it will still be back soon, since provoking factors will not go anywhere and will contribute to the resumption of the acute phase of the disease.

Groups of necessary drugs

As mentioned earlier, an integrated approach to the treatment of IBS is needed. In choise medical preparations You should follow exactly the same tactics to achieve a long-lasting desired result. Next, consider the main groups of drugs that are used in the treatment of this disease.

Lowering pressure

Elevated blood pressure has a negative impact on the work of the heart muscle. This is due to the fact that the squeezed vessels are worse than the oxygen, which causes oxygen starvation of the heart. Therefore, to control your pressure and keep it in the norm - the most important task with IHD.

To do this, use the following drugs:

APF inhibitors

• aCE inhibitors. They block the effects of substances that increase blood pressure, and minimize the negative impact of the other components on the heart, kidney, the liver. That is, this medicine contributes to a systematic pressure reduction;
• diuretics. Dorganic remedies contribute not only to a decrease in blood pressure and minimize the development of hypertension, but also impede the development of stolev in heart failure. It is also very important if there is a risk of developing brain edema, lung edema. Sometimes on early stages Hypertension of diuretics and are at all able to independently stabilize the blood pressure without the use of any other drugs. The most important thing at the same time also minimize the consumption of salt, as it contributes to the fluid delay in the body and thereby blocks the action of diuretics.

In case of ischemic heart disease, such medications will be required to prevent significant increase in blood pressure, as it sharply and significantly increases the load on the heart muscle, therefore such differentials should be avoided.

Improving heart work

In this case, the treatment of coronary heart disease drugs includes a variety of, which are aimed at solving the most different problems. Sometimes, at first glance, it may seem that some drugs do not particularly have a particular relation to this problem, but still it is always necessary to remember that all organs in the body are interconnected and therefore problems with one entails problems with Other bodies. That is why it is so important with serious heart problems to control the health status of other organs.

So, the main groups of drugs that contribute to the normalization of the work of the heart can be divided into the following main large groups:

Anaprin

• beta blockers. Such medicines block the effects of adrenaline on the heart muscle, or rather, inhibit it in the body. With serious heart problems, any experiences are destructive and therefore this factor is very important in this case. Also, similar drugs are able to eliminate arrhythmia, contribute to a decrease in blood pressure and reduce heart rate. Preparations are contraindicated with asthma and diabetes. Widely used after myocardial infarction. (Anaprilin, metoprolol);
• reducing blood viscosity medication. The more thick blood in humans will be - the harder it is to pump it, as well as the higher the risk of thrombus. Most often, aspirin is used for this purpose. It is shown to use mainly after surgery, as well as for the prevention of the occurrence of thrombus, if there is a predisposition or heredity. In more complex situations, it is necessary to use preparations for dissolving thrombus (if the thrombus has already been formed, but it is not possible to remove it);
• preparations to reduce sugar levels. But at the same time, it should immediately say that there are few hope for such drugs, if the patient does not comply with the basic recommendations, namely the diet;
• reduced cholesterol. It is this indicator in the blood contributes to development, as well as hypertensive disease. Ideally, if it is as small as possible in the blood of patients with IHS. For this, it is also necessary to comply primarily to the diet and minimize the consumption of animal fats. But it will not be possible to reduce such an indicator in one day and therefore, if necessary, it is very important to start receiving drugs in a timely manner to stabilize this indicator in the body. Statins are assigned for this purpose. Most often, the doctor appoints a constant reception of this group of drugs, but it is important to approach this issue With all seriousness, since the approach should be only integrated and in any way otherwise. Reception of drugs will be ineffective without compliance with the diet, and the diet without drugs will also not bring the expected results. That is why it is important to adhere to strictly all the recommendations of the doctor not only in matters of directly receiving drugs, but also in relation to nutrition;
• contraindications and side effects. The effect of drugs is essential to reduce the frequency of the heart muscle, but at the same time an increase in its intensity. Digoxin;
• nitrates. Preparations of this group are used directly to relieve the attack. They contribute to the expansion of coronary vessels and veins to reduce the influence of blood to the heart, which helps to reduce the load on it.
  Nitroglycerine

  Most often used from this group nitroglycerin. It reduces the oxygen starvation of the heart (as it reduces its need for oxygen), and also minimizes painfulness Either they eliminate them at all. The main disadvantage of nitrates is that the addiction of the body is developing and therefore, with long-term use, they cease to perform their functions and stop the attacks of angina. That is why for a long time they are prescribed only when heavy forms . At the same time, if they even cancel their reception, then soon they will again have the desired impact on the patient's body.
  Any medication from coronary heart disease can only be prescribed by the doctor, since many such drugs can possibly find a mass of side effects and contraindications and even with similar symptoms, an excellent preparation for one patient may be destructive for another. The doctor should always take into account the individual features of each patient and in accordance with them to compile a sheet of recommendations. Also, before this, it is necessary to undergo a comprehensive examination to identify the accompanying diseases and the degree of IBS.

Video

Ischemic (coronary) heart disease (IBS) developing due to atherosclerosis coronary arteries, It is the leading cause of disability and mortality of the working-age population throughout the world. In Russia, the prevalence of cardiovascular diseases and IHS is growing, and our country is in the first place in the world, which necessitates the use of modern and effective methods Their treatment and prevention. Among the population of Russia, the high distribution of the main risk factors for the development of the IBS are maintained, of which smoking, arterial hypertension, hypercholesterolemia have the greatest importance.

Atherosclerosis is the main cause of the development of the CHA. It proceeds hidden for a long time As long as it does not lead to such complications as myocardial infarction, brain stroke, sudden death, or to the appearance of angina, chronic cerebrovascular insufficiency, to intermittent chromotype. Atherosclerosis leads to gradual local stenosis of coronary, brain and other arteries due to the formation and growth of atherosclerotic plaques. In addition, in its development, such factors such as endothelium dysfunction, regional spasms, microcirculation disorders, as well as the presence of the primary inflammatory process in the vascular wall as possible factor Forming thrombosis. The violation of the balance of vasodilative and vasoconstrictor stimuli can also significantly change the state of the tone of the coronary arteries, creating additional dynamic stenosis to an existing fixed.

The development of stable angina may be predictable, for example, in the presence of factors causing an increase in the need of myocardium in oxygen, such as physical or emotional load (stress).

Patients with angina, including the myocardial infarction, constitute the most numerous group of patients with IHD. This explains the interest of practicing doctors to the issues of properly conducting patients with angina and the choice of optimal treatment methods.

Clinical forms of IBS. The CHD is manifested by a set of clinical forms: chronic stable angina, unstable (progressive) angina, asymptomatic IBS, vasospadic angina, myocardial infarction, heart failure, sudden death. The transient myocardial ischemia, originating usually as a result of the narrowing of the coronary arteries and increase the need for oxygen, is the main mechanism for the appearance of stable angina.

Chronic stable angina is made to divide on 4 functional classes in gravity of symptomatics (Canadian classification).

The main objectives of the treatment are the improvement of the quality of the patient's life by reducing the frequency of angina attacks, the prevention of acute myocardial infarction, improved survival rate. Successful antiagonal treatment is considered in the case of a complete or almost complete elimination of angina attacks and the return of the patient to normal activity (angina, not higher than i functional class, when pain attacks occur only with significant loads) and with minimal side effects of therapy.

In therapy of chronic IHD, 3 main groups of drugs are used: β-adrenoblays, calcium antagonists, organic nitrates that significantly reduce the number of angina attacks reduce the need for nitroglycerin, increase the portability of the physical activity and improve the quality of life of patients.

However, still practicing doctors reluctantly prescribe new efficient drugs in sufficient doses. In addition, in the presence of a large selection of modern anti-inanal and anti-hicemic drugs, outdated, not effective are not effective. Correctly choose the method of treatment helps a frank conversation with patients, explaining the causes of the disease and its complications, the need for additional non-invasive and invasive research methods.

According to the results of the ATR-SURVEY study (Angina Treatment Patterns), in Russia, when choosing antianginal preparations with a hemodynamic mechanism of action in monotherapy mode, preference is given to nitrates (11.9%), then B-adrenoblockers (7.8%) and calcium antagonists (2 , 7%).

β-adrenoblastors are preparations of the first choice for the treatment of patients with angina, especially in patients who have had a myocardial infarction, as they lead to a decrease in mortality and frequency of re-infarction. Preparations of this group are applied in the treatment of patients with IUD for over 40 years.

β-adrenoblockers cause an antiagonal effect by reducing the needs of myocardium in oxygen (due to the demolition of heart rate, reduction of blood pressure and myocardial contractility), increase delivery to the myocardium of oxygen (due to gain collateral blood flow, the redistribution of it in favor of the styled layers of myocardium - subendocardium), antiarrhythmic and anti-aggregation action, reduce calcium accumulation in the styled cardiomyocytes.

Indications for the use of β-blockers are the presence of angina, angina, with concomitant arterial hypertension, concomitant heart failure, "dumb" myocardial ischemia, myocardial ischemia with concomitant rhythm violations. In the absence of direct contraindications, the β-blockers are prescribed to all IBS patients, especially after myocardial infarction. The goal of therapy is to improve the distant forecast of the patient IBS.

The β-blockers are widely used propranolol (80-320 mg / day), atenolol (25-100 mg / day), metoprolol (50-200 mg / day), carvedilol (25-50 mg / day), bisoprolol (5 - 20 mg / day), nebivolol (5 mg / day). Preparations with cardiodelectivity (Atenolol, metoprolol, betaxolol) have mainly blocking influence on β 1 -adrenoreceptors.

One of the most widely used cardioslelective drugs is Atenolol (tenornmin). The initial dose is 50 mg / day. In the future, it can be increased to 200 mg / day. The drug is prescribed once in the morning clock. With a pronounced renal function daily dose must be reduced.

Another cardiodelective β-adrenoblocator is metoprolol (betalok). Its daily dose is 100-300 mg, the drug is prescribed in 2 receptions, since the β-blocking effect can be traced to 12 hours. Currently, the prolonged drugs of metoprolol - betal zok, metocardium, the duration of which reaches 24 hours.

Bisoprolol (Concorc) in comparison with the atenolol and metoprololol has a more pronounced cardiodelectivity (only β 1 -adrenoreceptors blocks and greater duration of action blocks in the therapeutic doses). It is used once per day at a dose of 2.5-20 mg.

Carvedilol (dilatrend) has a combined non-selective β-, α 1-block and antioxidant effect. The drug blocks both β 1 - and β 2 -adrenoreceptors, not possessing its own sympathomimetic activity. Due to the blockade of α 1 -adrenoreceptors, located in smooth muscle cells of the walls of vessels, carvedilol causes pronounced vasodilation. Thus, it combines β-adrenoblocking and vasodilating activity, with which it is mainly its anti-niaginal and anti-chemical effect, which persists during long-term use. Karvedilol also has a hypotensive effect and suppresses the proliferation of smooth muscle cells, which plays a pro -terogenic role. The drug is able to reduce the viscosity of blood plasma, aggregation of red blood cells and platelets. In patients with impaired left ventricular function (LV) or blood circulation deficiency, carvedilol has a favorably on hemodynamic parameters (reduces and post-loading), increases the emission fraction and reduces the size of the LV. Thus, the assignment of carvedilol is shown primarily to patients with IBS, who suffered a myocardial infarction, with heart failure, since this group of patients has proven its ability to significantly improve the prognosis of the disease and increase the life expectancy. When comparing Carvedilol (the average daily dose of 20.5 mg) and the atenolol (the average daily dose of 25.9 mg) was shown that both drugs appointed 2 times a day are equally effective in the treatment of patients with stable staining angina. One of the landmarks of the adequacy of the dose of β-adrenoblockers is to reduce the heart rate alone up to 55-60 rd / min. In some cases, less than 50 oct / min can be reduced in patients with severe angina stenquarters.

Nebivolol (Nate) - a new selective β 1 -adrenoblar, which also stimulates the synthesis of nitrogen oxide (NO). The drug causes hemodynamic unloading of the heart: reduces blood pressure, pre- and postload, increases cardiac output, increases peripheral blood flow. Nebivolol is a B-blocker with unique propertieswhich are the ability of the drug to participate in the process of synthesis cells of the endothelium of the relaxing factor (NO). This property gives the drug an additional vasodilative effect. The drug is used primarily in patients with arterial hypertension with the attacks of angina.

Coleiprolol (200-600 mg / day) - the third-generation β-blocker - differs from other β-blockers with high selectivity, moderate stimulation of β 2 -adrenororeceptors, direct vazodilative effect on the vessels, modulation of the release of nitrogen oxide from endothelial cells, the absence of adverse metabolic effects . The drug is recommended for Patients with chronic obstructive diseases of the lungs, dyslipidemias, diabetes, diseases of peripheral vessels caused by tobacco smoking. Coleiprolol (200-600 mg / day), atenolol (50-100 mg / day), propranolol (80-320 mg / day) have comparable anti-inanal efficiency and to the same extent increase the tolerance to the physical load of patients with a stable angina stress.

β-blockers should be given preference, assigning patients with IHD in the presence of a clear connection between the physical activity and the development of the attack of angina, with accompanying arterial hypertension; The presence of rhythm disorders (suctivativericular or ventricular arrhythmia), with a myocardial infarction, expressed alarm state. Most adverse effects of β-blockers are associated with the blockade of β 2 receptors. The need to control the appointment of β-blockers and encountered side effects (bradycardia, hypotension, bronchospasm, enhancing signs of heart failure, heart blockade, weakness syndrome sinus node, feeling fatigue, insomnia) lead to the fact that the doctor does not always use these drugs. The main medical errors in the appointment of β-adrenoblockers are the use of small doses of drugs, the appointment of them less often than is needed, and the abolition of drugs when the heart rate occurs at one time less than 60 ° C. It should also be borne in mind the possibility of the development of cancellation syndrome, and therefore β-blockers must be canceled gradually.

Calcium channel blockers (calcium antagonists).The main point of application of drugs of this group at the cell level is slow calcium channels, along which calcium ions are moving inside the smooth muscle cells blood vessels and hearts. In the presence of calcium ions, actin and miseos are interacted, ensuring the reduction of myocardial and smooth muscle cells. In addition, calcium channels are involved in the generation of the paister activity of the cells of the sinus node and the pulse through the atrioventricular node.

It has been established that the vasodilative effect caused by calcium antagonists is carried out not only by direct action on the smooth muscles of the vascular wall, but also indirectly, through the potentiation of the release of nitrogen oxide of the endothelium of vessels. This phenomenon was described for most dihydropyridines and isradipine, to a lesser extent - for nifedipine and nonhydropyridine preparations. For long-term treatment of angina, derivatives of dihydropyridines, it is recommended to use only prolonged dosage forms or long-term generation of calcium antagonists. Calcium channel blockers are powerful vasodilators, they reduce the need of myocardium in oxygen, expand the coronary artery. Preparations can be used in vasospast angina, concomitant obstructive pulmonary diseases. An additional indication to the appointment of calcium antagonists are Riino syndrome, as well as (for phenylaclamines - verapamil and benzodiazepines - diltiazem). Calcium antagonists in the treatment of IBS are used: nifedipine of an immediate action of 30-60 mg / day (10-20 mg 3 times) or prolonged action (30-180 mg once); Verapamil immediate action (80-160 mg 3 times a day); or prolonged action (120-480 mg once); diltiazem immediate action (30-60 mg 4 times a day) or prolonged action (120-300 mg / day once); Conducting Amlodipine preparations (5-1 0 mg / day once), Lazidipin (2-4 mg / day).

Activation of dihydropyridines (nifedipine, amlodipine) of the sympathetic system is currently being considered as an undesirable phenomenon and is considered the main cause of some increase in mortality of patients with IHD when taking short-range dihydropyridines when unstable angina, acute myocardial infarction and, apparently, with their prolonged use of patients with stable angina voltage. In this regard, it is currently recommended to use retal and prolonged forms of dihydropyridines. Of course, they do not have fundamental differences in the nature of pharmacodynamic effects with short-acting preparations. Due to the gradual absorption, they are deprived of a number of side effects associated with sympathetic activation, so characteristic of short-acting dihydropyridines.

IN last years Data appeared, indicating the possibility of slowing the damage to the vascular wall using calcium antagonists, especially in the early stages of the development of atherosclerosis.

Amlodipine (Norvask, Ambolus, Normodipin) is the third-generation calcium antagonist from the dihydropyridine group. Amlodipine expands peripheral vessels, Reduces post-loading of the heart. Due to the fact that the drug does not cause reflex tachycardia (since the sympatho-studary system does not activate), energy consumption and the need for myocardial oxygen decrease. The drug expands the coronary arteries and enhances the supply of myocardium by oxygen. Antianginal effect (reducing the frequency and duration of angina attacks, daily need In nitroglycerin), an increase in tolerance to physical exertion, improving the systolic and diastolic function of the heart in the absence of inhibitory effect on the sinus and atrioventricular node and other elements of the conductive heart system push the drug to one of the first places in the treatment of angina.

Lacidipin is a third-generation drug from the class of calcium antagonists - has a high lipophilicity, interaction with the cell membrane, as well as the independence of the tissue effects from its concentration. These factors are leading in the mechanism of anti-directosclerotic action. Lacidipin has a positive effect on endothelium, the formation of adhesion molecules, the proliferation of smooth muscle cells and platelet aggregation. In addition, the drug is able to inhibit the peroxidation oxidation of low density lipoproteins, i.e. it may affect one of the early stages of the formation of plaques.

In the European study of the influence of Lazidipine on Atherosclerosis (European Lacidipine Study On Atherosclerosis, ELSA), the thickness of the "intima-media" of the carotid artery in 2334 patients with arterial hypertension against the background of 4-year-old lacidipin or atenolol therapy was made. In the study included in the study patients, sleepy arteries were initially normal and / or modified. The treatment with lacidipine was accompanied by a significantly more pronounced compared to atenolol with a decrease in the "intima-media" thickness of both at the bifurcation level and the total carotid artery. Against the background of the treatment with lacidipin compared to the atenolol, an increase in the number of atherosclerotic plaques in patients was less than 18%, and the number of patients who had the number of plaques decreased, was 31% more.

Thus, calcium antagonists along with pronounced antiaginal (anti-ischemic) properties can have an additional anti-bean effect (stabilization of the plasma membrane, which prevents the penetration of free cholesterol into the vessel wall), which allows them to be prescribed them more often than patients with stable angina with damage to the arteries of different localization. Currently, calcium antagonists are considered to be the preparations of a second row in patients with stress angina, follow the β-blockers. As a monotherapy, they allow us to achieve an equally pronounced antiagonal effect, as well as β-blockers. The unconditional advantage of β-blockers in front of calcium antagonists is their ability to reduce the mortality of patients undergoing myocardial infarction. Studies of calcium antagonists after myocardial infarction showed that the greatest effect is achieved in persons without expressed dysfunction of the left ventricle, suffering from arterial hypertension, who have undergone myocardial infarction without teeth Q.

Thus, the undoubted advantage of calcium antagonists is a wide range of pharmacological effects aimed at eliminating manifestations coronary insufficiency: Antianginal, hypotensive, antiarrhythmic. Therapy has favorably affects the treatment with these drugs and during atherosclerosis.

Organic nitrates. At the heart of the anti-hypertension of nitrates is a significant change in hemodynamic indicators: a decrease in the pre- and post-loading of the left ventricle, a decrease in vascular resistance, including coronary arteries, decreased blood pressure, etc. The main indications for the reception of nitrates - angina stress and rest in patients with IBS (also in The aims of their prevention), the attacks of vasospadic angina, attacks of angina, accompanied by manifestations of left ventricular insufficiency.

Nitroglycerin sublingual (0.3-0.6 mg) or nitroglycerin aerosol (Nitromint 0.4 mg) Designed to relieve acute attacks Stenzardi due to the rapid start action. With poor nitroglycerin tolerance, nitrosorbide, molecid or calcium antagonist can be used to relieve the nitroglycery attack, chewing or resolving tablets when taking them under tongue.

Organic nitrates (drugs of isosorbide dinitrate or isosorbide-5-mononitrate) are used to prevent angina attacks. These drugs provide long-term hemodynamic unloading of the heart, improve the blood supply to the stylish areas and increase physical performance. They are trying to appoint exercisecausing angina. Of the drugs with proven efficacy, the most studied are cardic acid (20, 40, 60 and 120 mg / day), nitrosorbide (40-80 mg / day), Olicalland Retard (40 mg / day), mono poppy (20-80 mg / day ), mono poppy depot (50 and 100 mg / day), Efox Long (50 mg / day), mono chinckwe retard (50 mg / day). Patients with stable angina I-II FC may possibly intermittent appointment of nitrates before situations capable of causeing the appearance of an attack of angina. Patients with more heavily Stenzardia III-IV FC nitrates should be prescribed regularly; Such patients need to strive to maintain the effect throughout the day. Under angina IV FC (when angina attacks can occur at night) nitrates should be appointed in such a way as to ensure the effect during all day.

Nitrate-like drugs include Molomin (Corvaton, Sdanopharm, Dilacide), a drug, other than nitrates in a chemical structure, but not different from them by the mechanism of action. The drug reduces the stress of the vessel wall, improves collateral blood in myocardium, has anti-aggregation properties. Comparimed doses of Isosorbide of dinitrate and Corvaton are, respectively, 10 mg and 2 mg. The Corvaton effect is manifested in 15-20 minutes, the duration of action from 1 to 6 h (on average 4 h). Corvaton Retard 8 mg is taken 1-2 times a day, since the effect of the drug lasts more than 12 hours.

The weak side of nitrates are the development of tolerance to them, especially with long-term reception, and side effects that make them use ( headache, heartbeat, dizziness) caused by reflex sinus tachycardia. Transdermal forms of nitrates in the form of ointments, plasters and disks due to the difficulty of their dosing and development to them did not find wide use. It is also unknown, whether nitrates are improved by a patient with a stable angina during long-term use, which makes it doubtful the feasibility of their purpose in the absence of angina (myocardium ischemia).

When prescribing drugs with a hemodynamic mechanism of action, the following rules should be followed: to begin treatment with lower doses, carefully monitor the unwanted effects and always consider the possibility of replacing the drug in its poor tolerability and insufficient effectiveness.

Combined therapy. Combined therapy with antichangal drugs with patients with stable angina stage III-IV FC is carried out according to the following testimony: the impossibility of selecting effective monotherapy; the need to enhance the effect of monotherapy (for example, during the period of increased physical activity of the patient); correction of adverse hemodynamic shifts (for example, tachycardia caused by nitrates or calcium antagonists from a group of dihydropyridines); with a combination of angina with arterial hypertension or impaired heart rhythm, which are not compensated in cases of monotherapy; In the case of intolerance to the patients of generally accepted doses of drugs during monotherapy, the small doses of drugs can be combined to achieve the necessary effect.

Synergism mechanisms of action of various classes of anti-naiginal drugs is the basis for assessing the prospects of their combinations. In the treatment of patient with stable angina, doctors often use various combinations of antichannels (β-blockers, nitrates, calcium antagonists). In the absence of effect on monotherapy, combination therapy (nitrates and β-blockers are often prescribed; β-blockers and calcium antagonists, etc.).

The results of the ATP-SURVEY study (Review of the treatment of stable angina) showed that in Russia 76% of patients receive combined therapy with hemodynamic preparations, while in more than 40% of cases - a combination of nitrates and B-blockers. At the same time, their additive effects are not confirmed in all studies. In the methodological recommendations of the European Society of Cardiologists (1997), it is indicated that with the ineffectiveness of one anti-inanal drug, it is better to first estimate the action of another, and then use a combination. The results of pharmacological controlled studies do not confirm that the combined therapy of the B-adrenoblocator and calcium antagonist is accompanied by a positive additive and synergistic effect in most IBS patients. Purpose 2 or 3 drugs in combination is not always effective than therapy with one drug in an optimally selected dose. We must not forget that the use of several drugs significantly increases the risk of undesirable phenomena associated with the impact on hemodynamics.

A modern approach to combined therapy of patients with stable angina means implies the advantage of a combination of antianemic drugs of multidirectional action: hemodynamic and cytoprotective.

The main disadvantages of domestic pharmacotherapy of stable angina should be attributed often erroneous, according to modern ideas, the choice of a group of anti-indant drugs (as a rule, nitrates are prescribed (in 80%)), frequent use of clinically insignificant dosages and the unreasonable purpose of combined therapy with a large number of anti-inanal drugs.

Metabolic agents. Trimetazidine (preoccupative) causes inhibition of oxidation of fatty acids (by blocking the enzyme 3-ketoacyl coenzyme a-thiolase) and stimulates the oxidation of the pyruvate, i.e. it moves the energy metabolism of myocardium to dispose of glucose. The drug protects myocardial cells from the adverse effects of ischemia, while intracellular acidosis, metabolic disorders and damage to cell membranes decrease. A single reception of trimetazidine is not capable of stopping or preventing the occurrence of the attack of angina. Its effects are traced mainly when carrying out combination therapy with other antiagonal drugs or during courses treatment. Precuting is effective and well tolerated, especially in high-risk groups of coronary complications, such as patients with diabetes, elderly and with left ventricle dysfunction.

The combination predelled with propranolol was significantly more efficient than the combination of this β-blocker with nitrate. Trimetazidine (preoccupged 60 mg / day), predetal MV (70 mg / day) possess the anti-hiece effect, but more often they are used in combination with the main hemodynamic anti-naigneous drugs.

In Russia, a multicenter simply blind randomized placebo-controlled in parallel groups of TASTA (TRIMETAZIDIN IN PATIENTS WITH ANGINA IN COMBINATION THERAPY), which has embraced 177 patients suffering from angina-III FC, partially bought by nitrates and β-blockers for the purpose of evaluating efficiency preoccupied In combination therapy with nitrates or β-blockers. Evaluation of the effectiveness of treatment was carried out according to the following criteria: Time to the appearance of depression of ST segment by 1 mm during load samples, the occurrence of angina, the increase in the duration of the load sample. It was found that it predicts reliably increased the indicators. There are a number of clinical situations in which trimethazidine, apparently, may be a drug of choice in senior patients, in case of insufficient blood circulation of ischemic genesis, sinus-node weak syndrome, in the intanguability of anti-native funds of basic classes, as well as during restrictions or contraindications to their intended purpose. .

The drugs with antichangal properties include amiodaron and other "metabolic" drugs (Ranolazine, L-Arginine), as well as ACE inhibitors, selective inhibitors Heart rate (Ivabradin, Proleran). They are used mainly as auxiliary therapy appointed in addition to the main anti-inanimal means.

The problem of drug treatment of patients with IHD is the insufficient commitment to patients of selected therapy and insufficient willingness to consistently change lifestyle. With drug treatment, the proper regular contact of the doctor with patients is needed, informing the patient about the essence of the disease and the benefits of prescribed drugs to improve the forecast. Trying to affect the forecast of the life of patients with medication therapy, the doctor must be sure that the drugs prescribed by them are indeed taken by patients, and in the respective doses and under the recommended treatment regimen.

Surgery. With the ineffectiveness of drug therapy, surgical treatment methods are used (procedures for the myocardial revascularization), which include: percutaneous transluminal coronary angioplasty, implantation of coronary stent, operation of the aortocortonary shunting. In patients with IDAs, it is important to determine the individual risk on clinical and instrumental indicators, which depends on the appropriate clinical stage of the disease and the treatment. Thus, the maximum efficacy of coronary shunting is marked in patients with the greatest preoperative risk of developing cardiovascular complications (with heavy angina and ischemia, extensive lesions of coronary arteries, impaired LV function). With a low risk of developing the complications of the IBS (the defeat of one artery, the absence or slightly pronounced ischemia, normal function LV) Surgical revascularization is usually not shown until the inefficiency of drug therapy or coronary angioplasty is established. When the issue of using coronary angioplasty or coronary shunting for the treatment of patients with a lesion of several coronary arteries is solved, the choice of the method depends on the anatomical features of the coronary channel, the functions of the LV, the need to achieve complete revascularization of myocardium and the patient's preferences.

Thus, with existing methods of combating cardiovascular diseases today (Table) for a doctor, it is important to be aware of recent achievements Medicines and make the right choice of treatment method.

For questions about literature, please contact the editor.

D. M. Aronov, doctor medical Sciences, Professor V. P. Lupanov, doctor of Medical Sciences Gnitz Preventive Medicine Ministry of Health of the Russian Federation, Institute of Clinical Cardiology. A. L. Myasnikova Russian Cardiological Scientific and Production Complex of the Ministry of Health of the Russian Federation, Moscow

However, with the timely and active start of therapeutic measures, the development of the disease can be braked, significantly increase the duration and quality of the patient's life.

Risk factors

Key moment successful treatment of IBS Is the elimination of all risk factors:

• changing lifestyle
• decrease in blood pressure
• healthy nutrition and sleep,
• normalization of blood sugar, cholesterol,
• cessation of smoking
• physical activity, etc.

Medical treatment of IBS

More than half of success can be achieved without resorting to medicines. But for the greatest effect, medications must be taken supporting normal pressure, cholesterol and blood viscosity. Take medicines need constantly throughout life. From this depends on the success of treatment.

With a sharp deterioration of well-being ( decompensation) It is necessary to treatment in the hospital and reception additional drugs. This is especially true of the patients in the far-sighted stage of the disease and suffering from heart failure. With the help of properly selected treatment, these cases can be minimized. The smaller the patient calls for ambulance, and it becomes less likely to treat hospital, the better the quality control over the disease.

Surgical intervention with IHD

Surgical methods are used in the case of pronounced atherosclerosis of the coronary arteries, since no medication can reduce the size of cholesterol plaque or expand the clearance of the arteries, except surgical intervention. IN heavy cases of stagnant heart failure is the only effective tool Heart transplant remains.

Indications for hospitalization

• For the first time emerging pains for breasts (angina)
• First arising or severe attack of arrhythmia
• Progressive angina
• Decompensation of heart failure (sharp deterioration of well-being accompanied by an increase in edema, shortness of breath, changes to the ECG)
• Suspicions of myocardial infarction and other acute states
• Preparation for operational treatment

In other cases, IBA is successfully treated at home.

What medicines are used to treat IBS

Drugs that reduce blood pressure

Increased blood pressure negatively affects the blood vessels and other organs, as a result of which they are further compressed and less oxygen is obtained. Reduced and continuous maintenance of normal Hell is a key factor in the treatment of IBS. The target level of blood pressure with IHD is 140/90 mm.rt. and less for most patients, or 130/90 for patients with diabetes or kidney disease. For heavy patients, even lower numbers are recommended. In the overwhelming majority of cases, a constant technique of hypotensive drugs is required to achieve this level.

APF inhibitors

This is the class of drugs blocking angiotensin-2 enzyme, which causes pressure increase and other negative effects on the heart, kidney and vessels. Recently, many positive effects of ACE inhibitors are proved to forecast in patients with IHD, so they are prescribed as wide as possible, in the absence of contraindications. These include, for example, Enalapril, Leesinopril Perindopril and others. With prolonged use, the cough can cause cough, not suitable for all patients. Apply to the appointment of a doctor.

Blockers receptor angiotensin

These means allow you to block not angiotensin-2 itself, and the receptors to it are in various organs, including in the heart. In some cases, it is much more efficient. The sconium reduces pressure less efficiently than the IAPF, but they have several additional beneficial effects on the heart and vessels. In particular, some of them are able to stop the growing of the heart muscle (hypertrophy) and even reduce it a few percent. They are used in all groups of patients, and especially those who do not tolerate the IAPF.

Application Long, life, by appointing a doctor. Examples of drugs: Lozartan (Kozar, Lozart, Lorist), Valsartan (Valz, Diva, Valsakor), Kandesartan ("Ataandis"), Telmisartan (Macardis) and others.

The choice of a particular drug, the scheme of its use and dose refers to the competence of the doctor, since it is necessary to take into account the individual features of the course of the disease and the concomitant diseases.

Preparations that improve the work of the heart

Beta blockers

Block adrenaline receptors and other stress hormones in the heart. Reduce heart rate and blood pressure. Possessed on heart with arrhythmias and can eliminate it.

Recommended for continuous use in all patients after myocardial infarction and pre-infrack state, as well as with left ventricle dysfunction, regardless of the presence of heart failure, in the absence of contraindications. Application can be long or short-term, only by appointment of a doctor. Most of them are contraindicated with bronchial asthma, many increase blood sugar and do not apply during diabetes.

Examples of drugs: Anaprilin, metoprolol ("Egil"), Bisoprolol ("Concor") and others.

Nitrate

Basic medications for the relief (elimination) of the attack. These include funds such as Nitroglycerin (Nitromint), Isosorbide Dinitrate ("Izokt") and mononitrate ("Monocinx") and others. They act directly to coronary vessels and lead to their rapid expansion, and also reduce blood flow to Heart due to the expansion of deep veins that can stock blood. All this facilitates the work of the heart and reduces its need for oxygen, and therefore reduces oxygen starvation and pain.

Currently, nitrates are used mainly to relieve angina attacks, and for continuous use - in severe patients with chronic heart failure. All nitrates are addicted to all nitrates, and their effect is reduced over time, but after short cancellation it is restored again.

Cardiac glycosides

Digoxin, Corglikon, etc. Enhance the reductions of the heart muscle and slow them the frequency. Currently, it is infrequently applied in the treatment of IBS, mainly at shimmer arrhythmias and pronounced edema. There are many side effects, especially in combination with diuretic, and therefore should be appointed by a doctor only after a thorough examination.

Preparations that reduce cholesterol

• the level of total cholesterol should be no more than 5 mmol / l,
• low-density lipoprotein cholesterol levels ("bad") - no more than 3 mmol / l,
• high density lipoprotein cholesterol levels ("good") at least 1.0 mmol / l.

Also plays the role of the atherogenicity and level of triglycerides. In severe patients (for example, these indicators are recommended to be controlled even more stricter.

Target cholesterol levels are achieved by special diet and drugs. In most cases, one diet is not enough, but without it, the drug intake will not be so effective. Modern drugs They can significantly reduce cholesterol, but they must be taken constantly. Mostly for this, the drugs of the Statin Group (atorvastatin, Simvastatin and others are used). A specific drug appoints a doctor.

Preparations that reduce blood viscosity

The more viscous blood, the greater the likelihood of blood clots in coronary arteries and worse the blood supply of the heart muscle. To reduce blood viscosity, drugs of two groups are used: antiagregants and anticoagulants.

The most common antiagregant is aspirin. It is recommended to take every day to all patients with IBS all life at a dose of 70 - 150 mg per day (in the absence of contraindications, such as the ulcer of the stomach). Patients after operations on the heart and dose vessels can be raised by the appointment of the doctor, as well as added clopidogrel at a dose of 75 mg per day.

In patients with a permanent form of flickering arrhythmia, a doctor may assign a stronger medication - warfarin anticoagulant, in a dosage that provides maintaining the value of MNA (blood coagulation rate) at 2.0 - 3.0. Warfarin dissolves the thrombles more actively than aspirin, but may cause bleeding. It only applies to the appointment of a doctor after a thorough examination and control of blood tests.

Preparations controlling blood sugar (glucose) blood

The current criterion for control of diabetes is the level of glycated hemoglobin (HBA1C). It reflects the concentration of blood sugar for last week And should not exceed 7%. A single blood test on sugar does not reflect the true picture of the flow of diabetes.

To achieve the target level of sugar, all uncommon measures (diet, physical loads, weight loss) should be used, and in case of their insufficiency, a specific drug therapy For the appointment of an endocrinologist's doctor.

Other drugs

Diuretics (diuretic)

There are two applications: low doses to reduce blood pressure (most often in combination with other means), in high doses - to remove fluid from the body during stagnant heart failure. They have a property to increase blood sugar, so diabetes apply in extreme cases.

Antihypoxants

Antihypoxants are preparations that reduce the oxygen starvation of the heart muscle at the molecular level. One of these drugs is trimetazidine. It is not included in the standard CHA treatment schemes, can be used as an additional means. Not registered in the US Pharmacope.

Non-steroidal anti-inflammatory funds (NSAIDs)

Wide-consuming research in the United States revealed the harmful effect of this class of drugs on the forecast of patients undergoing myocardial infarction. In this regard, such medicines as diclofenac, ibuprofen is not recommended for use in people after a heart attack and equivalent states.

Influenza vaccination

Observation

Treatment time

The treatment of ischemic disease lasts all his life and should be carefully planned. In the period of observation, it is necessary to strictly adhere to the developed treatment regimen, and in the event of the appearance of side effects or deterioration of the state immediately access the doctor.

Many medications It is necessary to take for life. These include aspirin (or analogs), drugs against pressure, drugs for the normalization of blood sugar and cholesterol, and in some cases other drugs. A sudden cancellation of the medicine at one own request or even a decrease in the dose can lead to a sharp deterioration of well-being and decompensation, and this increases the likelihood of deadly complications (heart attack, heart stop, etc.).

Changes related to lifestyle and regime must be decisive and unconditional. Often, small flaws in the diet, such as an extra eased herring, can lead to a sharp jump pressure and impairment of the disease.

Visits to the doctor

Usually the doctor himself appoints the date of next visit. If he did not do this, ask him about it. Careful medical control and regular checks are a necessary and important component of treatment. If you are not sure or doubt the adequacy of the appointments of your attending physician, or want to get additional advice, contact a specialized advisory or diagnostic cardiac center.

Preventive hospitalization

IN former USSR Such a phenomenon was distributed as hospitalization to the hospital for prevention. In the case of IBA, such a strategy of therapy is not optimal in the point of view of the quality of control of the disease, nor from the point of view of the patient's commitment to treatment, and it must be avoided.

Treatment with interruptions, from time to time, does not provide with the necessary control over the risk factors and the course of the disease. Patients are beginning to be inclined to the idea that they are "must", after which they will again take care of the same life, and everything will be as before. This is a great misconception, which leads to a permanent reception of drugs, greater fluctuations in blood and pressure indicators, absence of disease control.

For one or two weeks, carried out in the hospital once in half a year, it is impossible to achieve a real change in the course of the disease, except for some symptomatic improvement. Many patients perceive this improvement as a small victory over the disease, and continue to live former life. However, it is not at all like this: ischemic illness without changing the lifestyle and supporting drug intake continues to progress, ending with a sudden death or infarction. It is possible to reduce your risk and extend the life only long, rather than periodic therapeutic effects.

The main antianginal drugs include nitrates, beta-blockers and calcium antagonists.

Nitrates. The effectiveness of nitrates is well known when the attacks of angina and during prophylactic reception begun before loading. However, with constant reception of nitrates, for example, daily 3-4 times a day, there is a tolerance to nitrates with a decrease or disappearance of anti-hicemic action. To prevent the development of tolerance, it is advisable to take a break for at least 10-12 hours for a day, i.e. Assign nitrates or predominantly during the daytime, or only for the night (depending on the specific situation), and for permanent admission to use the drugs of other groups.

It should be remembered that the use of nitrates does not improve the forecast, but only eliminates angina, i.e. It is symptomatic.

Beta blockers. Beta blockers are a means of choosing in the treatment of stress angina. In addition to the antianginal effect, the sign of sufficient beta blockade is the gentleman's gentlement less than 60 per minute and the absence of pronounced tachycardia under load. With the initial pronounced bradycardia, for example, at a heart rate of less than 50 per minute, beta blockers with internal sympathomimetic activity (beta-blockers with ACCs), for example, pindolol (wickey) are used.

Calcium antagonists. Calcium antagonists are a choice of spontaneous ("vasospast") angina. With a stainlessness of the voltage, such calcium antagonists, like verapamil and diltiazem, are almost also effective, as well as beta-blockers. It should be recalled that the use of short-live forms of nifedipine is currently not recommended. Preference should be given to verapamil, diltiase and prolonged forms of dihydropyridine calcium antagonists (amlodipine, feelodipine).

The appointment of other drugs is substantiated in refractoriness to the "standard" therapy, the presence of contraindications to the appointment of a group of anti-inanal drugs or their intolerance. For example, if there is contraindications to beta-blockers and verapamil, you can try to use Curdaron.

There are reports about the anti-naiginal effect of Euphilline: the reception of the euphilline reduces the manifestation of ischemia when sample with load. The mechanism of antichangal action of the Euphillin is explained by the T. N. The "Robin Guda effect" is to reduce the vasodilation of unaffected coronary arteries (antagonism with adenosine) and the redistribution of blood flow in favor of the styled portions of myocardium (the opposite of the "phenomenon of the breaking"). In recent years, it has been evidence that the addition of mildronate cytoprotective drugs or trimethazidia can increase the anti-hiece effect of anti-inanal drugs. Moreover, these drugs have their own anti-host effect.

In order to prevent the occurrence of myocardial infarction and sudden death to all patients, aspirin is prescribed at 75-100 mg / day, and in its intolerance or presence of contraindications - clopidogrel. Many experts believe that the appointment of statins is also shown to all patients with IHD, even with normal level cholesterol.

Antianginal drugs

A drug	Average daily dose (mg)	Frequency reception
Nitroglycerine	By need
Nitrosorbid.
Trinitolong
Ointment with niroglycerin
Izoket (cardic) -120
Izoket (cardic) retard
Isosorbide-5-Mononirate (Monocinque, Efox)
Plock Nitroderm
Molomin (Corvaton, Dilaside)
Beta blockers
Propranolol (Obizant)
Metoprolol (Methodocard, Corvitol)
Oxprenolol (trazicor)
Pindolol (Viscome)
Nadolol (Corgard)
Atenolol (tenorn)
Bisoprolol (Concorp)
Carvedilol (dilatrend)
Nebivolol (root)
Calcium antagonists
Verapamil (Isopin SR)
Nifedipin Gits (OSMO Adalat)
Diltiazese (Dilren)
Diltiazese (Altiazem RR)
Isradipine (Lomir sro)
Amlodipine (Norvask)
Additional drugs
Cordaron
Eufillin
Mildronat (?)
Trimetazidine (?)

Features of the treatment of various versions of angina

Threw stress

Comparatively low-active patients with moderately pronounced angina, especially in old age, it is often sufficient to recommend the receipt of nitroglycerin in cases where the attack does not pass independently after stopping the load for 2-3 minutes and / or the preventive intake of the isosorbide of dinitrate before loading, for example, nitrosorbide 10 mg (under the tongue or inside) or isosorbide-5-mononitrate 20-40 mg inside.

With a more pronounced angina tension, beta blockers are added to treatment. The dose of beta-blockers is selected not only by the anti-inanimal effect, but also by influence on the heart rate. CSS should be about 50 per minute.

In the presence of contraindications for beta-blockers or in case of insufficient treatment, beta-blockers are used calcium antagonists or prolonged nitrates. In addition, instead of beta blockers you can use amiodaron. With angina pharmacy of the III-IV FC, combinations of 2-3 drugs are often used, for example, a constant reception of beta-blockers and calcium antagonists and preventive reception of prolonged nitrates before loading.

One of the most frequent errors When appointing antianginal drugs is their use in insufficient doses. Before replacing or adding the drug, it is necessary to estimate the effect of each drug in the maximum portable dose. Another error is the purpose of constant reception of nitrates. Nitrates are appropriate to assign only before the planned load, which causes angina. Permanent reception of nitrates is useless or even harmful, because It causes the rapid development of tolerance - progressive reduction or complete disappearance of antiagonal action. The effectiveness of drugs is constantly monitored to increase the tolerability of physical exertion.

Patients with preservation of heavy angina (FKIII-IV), despite drug treatment, is shown to conduct coronoagographics to clarify the nature and degree of damage to coronary arteries and assessing the possibility of surgical treatment - balloon coronaugulagioplasty or aortocortonary shunting.

Features of the treatment of patients with X syndrome. X syndrome is called the stress angina in patients with normal coronary arteries (the diagnosis is established after the coronary frame). The cause of syndrome X is the reduction of the ability to vasodilat the small coronary arteries - "microwave angry".

In patients with syndrome X, surgical treatment is impossible. Pharmacotherapy in syndrome X is also less effective than in patients with stenosis of coronary arteries. It is often noted refractoriness to nitrates. Antianginal effect is observed about half of the patients. Medical treatment is selected by the method of trial and error, primarily assess the effectiveness of calcium nitrates and antagonists. In patients with inclination to tachycardia, treatment starts with beta-blockers, and in patients with bradycardia, there may be a positive effect from the destination of Euphilli-on. In addition to antianginal preparations, the A-1-blockers can be effective in syndrome X, for example, doxazosin. Additionally uses such drugs like mildronat or trimetazidine. Considering that patients with syndrome X have a very good forecast, the basis of therapeutic measures is rational psychotherapy-explanation of the safety of this disease. Adding to antichangal prepartes of imipramine (50 mg / day) increases the effectiveness of therapeutic measures.

Spontaneous angina

To relieve seizures of spontaneous angina, primarily use sublingual reception of nitroglycerin. In the absence of effect, nifedipine is used (the tablet is chewed).

To prevent the occurrence of repeated seizures of spontaneous angina to the choice of calcium antagonists. Calcium antagonists are effective about 90% of patients. However, it is often necessary to use the maximum doses of calcium antagonists or a combination of several drugs of this group at the same time, up to the use of all three subgroups at the same time: verapamil + diltiazem + nifedipine. With an insufficient effect, prolonged nitrates add to treatment. For several months, most patients have a noticeable improvement or complete remission. Especially often the rapid disappearance of inclination to spastic reactions and long remission It is observed in patients with isolated spontaneous angina, without concomitant angina stress (in patients with normal or low-change coronary arteries).

Beta blockers can enhance inclinations to coronary arterial vasospadic reactions. Nevertheless, if the attacks of spontaneous angina appear in a patient with a pronounced stress angina, calcium antagonists are used in combination with beta-blockers. The most appropriate use of Nibivolol. There are reports of pretty high efficiency cordaron. In some patients, the appointment of doxazozin, clonidine or nico-randil.

Night angina

3 options are possible: angina walls of minimum stresses (angina, arising in the lying position - "Dtencardia Decubitus" and angina during dreams with an increase in heart rate and blood pressure), angina region due to blood circulation deficiency and spontaneous angina. In the first two cases, angina region is equivalent to paroxysmal night shorts. With all 3 embodiments, the appointment of nitrates of prolonged action per night (prolonged forms of isosorbide of dinitrate and mononitrate, nitroderma patch, nitroglycerin ointment) can be effective. With an estimated diagnosis of angina stress angina - it is advisable to estimate the effect of beta blockers. With spontaneous angina, calcium antagonists are most effective. In case of insufficiency of blood circulation, nitrates and ACE inhibitors are prescribed. Consistently evaluating the effectiveness of the destination various drugs and their combinations, select the most acceptable treatment option.

Surgical methods of treating IBS

The main indication for the surgical treatment of IBS is the preservation of severe angina (FC III-IV), despite the intensive drug treatment (refractory angina). The presence of angina stenocardium III-IV FC means that pharmacotherapy is not effective enough. The testimony and nature of surgical treatment are specified on the basis of the results of coronaryogiography, depending on the degree, prevalence and features of the damage to the coronary arteries.

There are 2 main methods of surgical treatment of IBS: balloon coronaugorallasty (cap) and aorticoronary artery shunting (AKSH).

Absolute readings to AKS are the presence of the stenosis of the furnace coronary artery trunk or three-sideways, especially if the emission fraction is reduced. In addition to these two testimony, the Conduction of the AKS is appropriate in patients with a two-way lesion, if there is proximal stenosis of the left front downward branch. Conducting ACCH in patients with stenosis of the leather coronary artery stenosis increases the life expectancy of patients compared with drug treatment (survival rate for 5 years after AKSH - 90%, with medication treatment - 60%). Slightly less effectively carrying out AKS with a three-dimensional lesion in combination with left ventricle dysfunction.

Coronoangioplasty is the method of t. N. Invasive (or interventional) cardiology. When conducting coronaohangioplasty, as a rule, stents are introduced into the coronary artery - metal or plastic endovascular prostheses. Against the background of the use of stents, a decrease in the frequency of the occurrence of the occurrence of the occurrence of the occurrence of reflux and restenosis of coronary arteries by 20-30% was noted. If after the cap during the 1st year there is no restenosis - the forecast for the next 3-4 years is very good.

The remote results of the cap are not yet studied. In any case, the symptomatic effect is the disappearance of angina - it is noted in most patients.