By modern classification The IBS includes sudden death, angina and myocardial infarction. But this section will only be considered by IWC in the manifestations of angina. This is a heart disease group (especially ischemic and coronary failure) arising from the violation of blood flow to myocardium due to the narrowing of the coronary

Term "ischemia" There was a combination of Greek words LH / Yu, which means "delay, stop", and NTTA - "Blood". At the same time, blood supply is broken in any section of the heart, the discrepancy between the needs of the heart (myocardium) in oxygen and the level of heartflow and incoming oxygen appears. This condition can be acute and chronic, to be temporary (reversible) and irreversible.

As a result of long, irreversible changes in the myocardial portion, cardiac cells are damaged and dying. IHD manifests itself when the narrowing coronary vessels reaches 50%. If the narrowing approaches 70-80%, there are pronounced seizures of angina. In addition to atherosclerosis coronary arteriesIn the emergence of IBS, a number of factors are important - the state of the vessels and the number of chemicals, which produce the inner walls of blood vessels.

Atherosclerosis - this is chronic illnessAt which the defeat of the arteries occurs. It is expressed in that inner wall The vessels are laid fats and calcium salts, the rebirth of the muscular fabric is developing into the connecting. As a result, the vessel wall is compacted, its narrowing occurs, the blood flow is disturbed. This causes adverse changes in the organs, which leads to various diseases. Atherosclerosis is one of the most common contemporary diseases. Its prevalence is great among residents of Europe, North America, and in the countries of the East, in Africa, South America He meets much less often.

Men sick more often than women, and atherosclerosis, they arise about 10 years earlier. Such a difference is due to lifestyle, genetic features, hormonal factors. Over the past decades, mortality from IBA has significantly increased, the reason for which atherosclerosis appeared. The occurrence of atherosclerosis is due to a combination of many factors that bear the name of risk factors. These include: arterial hypertension, smoking, long-term emotional loads, metabolism of metabolism in the body.

The mechanism of the occurrence of atherosclerosis: the inner casing of the vessel is damaged, platelets are rushed into place of damage, they are settled there, covered connective tissue With the subsequent attachment of lipids. Cholesterol is one of several residential-like compounds found in the blood and tissues of a person. It is generated by liver cells. Cholesterol exists in the body in several types. One of them is high density compounds. This part is very important, as it protects the body from atherosclerosis, makes cholesterol from the tissues of the body and the walls of the arteries, returns it to the liver to reuse or remove it from the body. Another part of cholesterol - low density compounds. It is she who plays a role in the formation of plaques and the development of atherosclerosis.

Gradually, the process is progressing, cracks, ulcers are formed on plaques, and swarms are formed on their surfaces. They close the clearance of the arteries. Thrombosis occurs. The most terrible complication in this is a tomb of thromba. There are more than 30 factors that contribute to the emergence of IBS, it is an increase in blood pressure, an increase in blood cholesterol, smoking, a sedentary lifestyle, frequent use of alcohol, heredity (disease availability of cardio-vascular system Close relatives), belonging to the male floor, an objective process of aging of the body, overwork, an inexultuous mode of work and recreation, irrational nutrition, stressful situations.

Stress in our days, many times increases the risk of EBS. In stress conditions, the human body produces so-called stress hormones. In the process of this spent a large number of Vitamins and nutrients. It is also very important to change the composition of blood - accelerating blood coagulation, which leads to the gluing platelets and ultimately to the formation of plaques and thrombus.

Clinical manifestations

Angina - The most important and common manifestation of IBS. This common disease, the main symptom of which is pain behind the sternum or compressive nature. Pain applies, gives to the left hand, shoulder, shovel, often in the neck and lower jaw. Stenokard attack can manifest itself in the form of discomfort in breasts - burning, gravity, cutting. A characteristic symptom For angina disease is the appearance of sternum pain when the patient is out of the warm room in the cold. Often the deterioration is observed in the autumn-winter period, with a change in atmospheric pressure. Pain occurs during exercise (in the initial stages of the disease - the so-called angina stress) and stops alone or after taking nitroglycerin. With the excitement of pain appear out of physical voltage.

Pain attacks may arise at night, after eating, when the abdomen and the high position of the diaphragm. The duration of the attack of angina is almost always more than 1 minute and less than 15 minutes. Its duration depends on the behavior of the patient. If you stop physical load and adopt nitroglycerin, the attack will be shorter and less intense. One of the signs of angina is that the pain is intensified in the lying position and decreases when the patient sits or stands. This is because in the position lying intensifies the influx of venous blood to heart and myocardium requires more oxygen. The strength of the attack is different. At this time, the pulse is usually slow, rhythmic, but sometimes it can be accelerated (tachycardia), arterial pressure can also be improved. The attacks can be rare (once a week or less), may not be repeated for several months or, on the contrary, becoming increasingly frequent and long.

In diagnosis IBS A patient asked very important, finding out the causes of the disease, an electrocardiographic study, which is repeated repeatedly, samples with dosage physical activity (cyerurgomegriya), drug samples. One of the modern methods carried out in cardiology hospitals is a radiographic study of the blood vessels, that is, the introduction of a substance in the blood, thanks to which it is possible to see the heart and large vessels and determine the nature, place of defeat, the prevalence of the process. This method is called "Coronoangiography".

Treatment

Traditional

Treatment IBS - this is comprehensive program. It includes methods traditional therapyprescribed by therapists and cardiologists, and methods of non-traditional, traditional medicine. The obligatory component of treatment is the fight against risk factors. It is necessary to normalize the lifestyle of the patient, eliminate hypodynamine, eliminate bad habits, stick to a certain power mode, try to avoid unrest and emotional overloads.

Medical nutrition

The list of products needed by patients with this disease must necessarily include raisins, honey, nuts of any species, raw pumpkin, pumpkin seeds, sea cabbage, cottage cheese, strawberries. Peas, soybean, soybean oil and flour, eggplants, lemons and oranges with zest, rosehip in the form of a drink, gooseberry, cranberries. The content of proteins, fats and carbohydrates should relate as 1: 1: 4. With excess body, it is important to reduce the calorie food. It is necessary to exclude fatty meat from the diet (especially mutton and pork), solid margarine, butter, replacing it with vegetable, i.e. it is necessary to reduce the content of saturated fatty acids in used products, which are rich in animal fats, contributing to the formation of cholesterol, and increase Number of fats vegetable origin. In addition, it is necessary to provide the body with an increased amount of vitamins and trace elements.

Drug therapy includes two main groups of drugs. This is, firstly, nitroglycerin and its derivatives longer action (they remove spasm and expand the coronary vessels, due to which blood access and oxygen is facilitated). Another group is drugs that contribute to improving blood composition (in this case, reducing clotting and preventing blood clots). Most. simple drug Of these, aspirin (acetylsalicylic acid) appointed according to a specific scheme. In addition, in some cases, medications are recommended that reduce cholesterol formations in the blood and inhibiting its absorption in the intestine. Also used drugs that accelerate metabolism and elimination of lipids from the body.

Very useful is the purpose of vitamins E and R. more appropriate to their combination with ascorbic acid. It must be remembered that all pharmacological preparations must appoint a doctor. Self-treatment with these means is unacceptable. In addition to the above funds, in the treatment and rehabilitation of patients with IBS, physical training is very important. In the initial manifestations of the disease, running, swimming, skiing, bike, i.e. physical exertion of cyclic type.

They should be carried out during periods outside the exacerbation of the disease. With more heavy forms IBS Physical exertion is recommended in the form of complexes of medical gymnastics. The complex for therapeutic physical education should be selected by the physical physical physician with the heart of the patient. Classes are asked by the instructor on therapeutic physical education by the group method in a hospital or polyclinic under the control of the doctor. It is necessary to measure the pulse before, during and after classes. Usually, these complexes include exercises in the initial position standing, sitting (for patients older than 50 years), walking, exercises for the upper and lower limbs using a gymnastic stick, breathing exercises and sipping. Exercises are performed at a slow pace, smoothly, with a small amplitude of movements.

As a "unloading" of the work of the heart you need to use self-massage limbs. This is carried out in order to relieve 01 Oka blood from the periphery to the center. The most simple techniques of massage: stroking, rubbing, kneading. After a certain course of therapeutic physical education in the LPU, the patient can independently perform these exercises at home. In the treatment of patients with IBS, you can not forget about the use physical factors (methods of hardware physiotherapy). The type of physiotherapeutic treatment is selected by a physiotherapist.

In the absence of contraindications (such as progressive angina, resistant pain syndrome, resting angina, an increase in blood pressure, the presence of arrhythmias) used balneotherapy sessions - carbon dioxide, radon, chloride and yodobromic medical baths. In patients with more pronounced angina, these impacts are applied gentle - in the form of four-chamber baths. Good soothing effect give an "electrosone", galvanic collar, electrophoresis of painkillers and sedatives.

In the absence of contraindications, you can use combinations of therapeutic baths and hardware physiotherapy. In specialized cardiological clinics and hospitals, laser therapy method of various types of laser radiation is widely used.

Phytotherapy

Requires: 2 tbsp. l. Rosehip fruits, 350 ml vodka.

Cooking method.

Rosehip fruits finely exterminate, pour into a glass bottle with a capacity of 0.5 liters, pour vodka. Insist in a place protected from light 2 weeks, shake daily.

Mode of application.

Take 20 drops on a piece of sugar 3 times a day, regardless of meals.

Requires: 5 g of fresh shine roots.

Cooking method.

Crumpled roots Khrena pour in thermos 1 glass of boiling water, insist for 2 hours. You can not polish.

Mode of application.

We use infusion for inhalations.

Requires: 1 tsp. Straight flowers.

Cooking method.

Flowers of nettles pour 1 glass of boiling water.

Mode of application.

Take 0.5 glasses 2 times a day: in the morning on an empty stomach and in the evening before bedtime.

Requires: 1 part of the leaf of coltsfoot, 2 pieces of vegetable dill fruits. The herbs of the jaundice, tongue flowers of sunflower, 1 l of steep boiling water.

Cooking method.

All components mix thoroughly, grind. 1 tbsp. l. The obtained collection is pouring steep boiling water, insist for 1 hour. It is obtained to strain, raw materials.

Mode of application.

Take 1/2 cup 5-6 times a day for a month, regardless of meals.

Requires: In 40 g of grass, a lovery of medicinal, crushed corn roots, 1 liters of boiled water.

Cooking method.

Ingredients mix, crush. 2 tbsp. l. The obtained collection is pouring with boiled water, bring to a boil, boil 7-8 minutes, pour into thermos and insist 40 minutes. The resulting decoction to strain, squeeze raw materials.

Mode of application.

Take 1/2 cup 3 times a day 30 minutes after receiving write. Conduct 3 courses to 7 days with a five-day interval.

Requires: 1 part of the layer of laminaria sharacte, 2 pieces of cornflowers, grass horsetail, Rosyanka grass, 1 liter of boiling water.

Cooking method.

Ingredients mix thoroughly, crushing. 3 tbsp. l. Put the obtained collection in enameled dishes, pour 1 liter of boiling water. Put on a water bath and bring to a boil. Boil for 1 min. Pour to thermos, insist 1 hour. It is obtained to strain, pour raw materials.

Mode of application.

Take 1/2 cup 6 times a day, preferably after meals, for 2 weeks.

Requires: In 20 g of flowers, the vasilka blue, kidney of birch, crushed rhizomes with the roots of nine-sided, cornflowers, leaf of tocheries, buckwheat flowers sowing. 1 cup of steep boiling water.

Cooking method.

All ingredients mix thoroughly, crushing. 2 tbsp. L, fenced to the enameled dishes, pour 1 glass of boiling water, put on a water bath, bring to a boil. Adjust to cool. The resulting decoction to strain, squeeze raw materials, bring to the original volume with boiled water.

Mode of application.

Take 1/2 cup 2 times a day 30 minutes before meals. It is not recommended to use for the night.

Requires: 1 parts of the root of a century tea, linden flowers. Fruit of raspberry, linen ground seed, 2 glasses of steep boiling water.

Cooking method.

All ingredients mix thoroughly, crushing. 4 tbsp. l. Put the received collection into enameled dishes, pour boiling water, put on a water bath and keep 30 minutes. Adjust to cool. The resulting decoction to strain, squeeze raw materials, bring to boiled water to the original volume.

Mode of application.

Take 1 cup 2 times a day directly 5-7 minutes before receiving write. Apply within a month. With insufficient effectiveness, the course is repeated after a two-week break.

Requires: 20 g of grass horseways, 30 g Highlander Highlander (Speech), 50 g of hawthorn flowers, 1 cup of steep boiling water.

Cooking method.

Grinded raw materials mix. 2 tbsp. l. Calculate boiling water. Stir, insist before cooling. Folded to strain, raw materials.

Mode of application.

Drink during the day.

Requires: 2 tbsp. l. The crushed root of the roast of garden, 1 cup of honey, 1 cup of freshly prepared carrot juice, 1 glass of boiled water.

Cooking method.

Had to pour water and leave for a day. Add honey and carrot juice. Mix. Store in a cold place.

Mode of application.

Take 1 tbsp. l. An empty stomach is 1 hour before meals or 1.5-2 hours after meals.

Requires: 2 tbsp. l. Shredden roots of blue blue.

Cooking method.

Pour raw materials 100 ml of boiling water, keep 10 minutes on low heat. Insist for 15 minutes, then strain and bring to the initial volume with boiled water.

Mode of application.

Take 1 st, l. 5 times a day after meals. Last time to take overnight.

Requires: 20 g leaves strawberries.

Cooking method.

Pour the raw material with 1 cup boiling water, boil for 10 minutes, then insist 2 hours, strain, leaves, bring to the original volume with boiled water.

Mode of application.

Take 1 tbsp. l. 3-4 times a day, regardless of meals.

Requires: 50 g garlic, 1 cup of vodka.

Cooking method.

Garlic crushed, pour vodka, insist in warm place for 3 days.

Mode of application.

Take 3 times a day at 8-10 drops of 1 tsp. Cold boiled water 3 times a day, regardless of meals.

Requires: 350 g of garlic, 200 ml of medical alcohol fortress 96%.

Cooking method.

Peeled garlic finely chopped and rub in a wooden spoon in a container. Take the bottom of 200 g of this mass together with the juice obtained, put into the vessel of glass, pour alcohol, tightly wait. The resulting tincture is not in the refrigerator no more than 12 days.

Mode of application.

Take 20 minutes before meals, pre-mixing with 1/4 cup of cold milk, within 10 days according to the following scheme: in the 1st day 1 drop in the morning, 2 drops at lunch, 3 drops before dinner. In the 2nd, 3rd, 4th and 5th day, add 3 drops to the reception. From the 6th to the 10th day, subsidize 3 drops to the reception.

Requires: 1 tsp. Leaf of mistletoe white, 2 tbsp. l, buckwheat flowers, 1 glass of boiling water.

Cooking method.

1 tsp. Pumps up boiling water, put on the night in a warm place, to strain in the morning.

Mode of application.

Take 2 tbsp. l. 20 minutes before meals 3 times a day.

Treatment of IBS by folk remedies: feature of the disease and methods of its treatment

Today, cases of heart disease are increasingly registered. And one of the most common is ischemic heart disease, which in inadequate treatment and in late detection can lead to full outcome. And the treatment of this disease is usually carried out comprehensively, applied as standard medical preparationsand the funds of traditional medicine.

Causes and factors contributing to the development of IBS

Before moving to the main methods of treatment ischemic Disease folk remedies, you need to know why it arises, and what factors provoke it.

But the main reason for the occurrence of IBS is the deposition of fat plaques that interfere with the normal flow of blood in the heart, as well as its further transportation throughout the body.

Also, factors such as the development of IBS contribute to:

• Frequent increase in blood pressure, which is most often due to stress, as well as due to weak nervous system, and, of course, because of other problems with the heart and blood vessels
• Not an active lifestyle, due to which the body loses many, including becomes unacceptable for any changes. The body does not consume so much energy as it is necessary for normal operation. And besides, a sedentary lifestyle leads to weakness of all muscles, which very negatively affects the work of the heart
• Incorrect meals These are usually attributing with sharp dishes, as well as very fat and sweet food. Few people thinking, a king hamburger, that because of him, problems with the heart can begin
• Overweight and obesity. Since the main reason for the development of IBS is the deposition of fat plaques, then in the case of very complete people, this process is much faster, since the body practically consists of their fat. Yes, and the load on the heart during an overweight increases many times
• Smoking. Everyone knows that the tobacco (nicotine) adversely affects the body, namely pollutes the lungs. And if there is an insufficient amount of oxygen in the lungs, and besides, he is poisoned by nicotine, he suffers from this heart
• Heredity. Heredity plays a major role in the development of the disease. It is believed that if someone from close relatives have this disease, then the chances that it will develop, significantly increase
• Diabetes. In diabetes, blood becomes much thicker than the body requires. And therefore, people suffering from diabetes develop many other diseases.
• Frequent stresses that lead to the fact that the heart does not withstand constant excitement and begins to work accelerated, because even with weak emotional tension need much more oxygen and nutrients to support normal work All organs
• Disease blood
• Priced work schedule, as well as constant non-compliance with the regime and recreation, which leads to the timing of the entire body

Despite the fact that the public awareness of the ischemic heart disease is high, anyway, few people hold a healthy lifestyle to avoid the development of the problem.

Symptoms of Disease

Everyone should know the basic symptoms of the manifestation of this disease, since the earlier it was discovered and the steps were taken to improve the condition, the better it would be for the person himself.

So, the main symptoms of the IBS can be attributed to:

• The painful sensations behind the sternum, which can be like a godic and compressive nature. Mostly they are not strong, but still make a person, for example, will stop while walking
• Feeling burning in the heart
• The painful sensations that appear at the moment when a person leaves the room to the cold
• Pain attacks can happen at any time, there is no clear dependence on the day and night. True, many patients celebrate, most often pain appear in autumn or in winter, when the weather is very unstable and the atmospheric pressure is constantly changing
• Pain is usually enhanced if a person wants to lie down. But if he sees or gets up, the pain either subsides, either will pass at all

It should also be said that the attacks may happen just a week, and once every six months. But at a severe stage, they can occur every day, forcing a person to change their lifestyle.

Treatment of disease. Food

Quite often, many problems can be solved by changing their diet. And IHS is no exception. Of course, adding some products will not save completely from the disease, but to significantly improve the state and reduce the number of pain attacks may well.

Now people who suffer from coronary heart disease are recommended to add to the diet:

• Cheremshu.
• Onion. It is famous for his healing properties. True, it does not mean that it is necessary to eat his kilograms. A small piece once a day - this will be enough
• Blackberry. It can be eaten in any form. True, it is fresh selling it only in the summer, but it's frozen, from which you can cook compotes, can be found in any major supermarket
• Black currant. This berry is not only delicious, but also very useful. It also needs to be used in any form (compote, jam, etc.)
• Cabbage that mono eat like in fresh formadding to salads and in boiled or stew
• Apples and pears. They can also be eaten in absolutely any form, since beneficial features Store always
• Watermelon. This is a very useful berry, however, natural, without additives, watermelon can only be bought for two months a year. But even at this time you need to eat at least two kilograms per day
• Corn, which can be simply cooking, or acquire a corn crucible and cook from her porridge
• Apricots
• Hawthorn. which you need to dry and brew

Of course, adding all these products to the diet will not heal, but will significantly improve the condition of the heart and blood vessels. In addition, those who want to get rid of the disease or at least reduce the number of attacks, you need to completely eliminate greasy dishes, since it is precisely most often the cause of a large cholesterol content in the blood. A high cholesterol leads to the deposition of plaques.

Folk remedies. Decorations

Most often, people resort to the help of scales:

1. Recipe 1. You need to take 150 grams of the roots of the poduelnik and pour them with 2 liters of cold water, then mix well. After that, put on fire and let boil. Keep decoction in the refrigerator, as it can quickly spoil
2. Recipe 2. You need to take Fennel, about ten grams. You only need to take fruit. Then pour boiling water (one glass) and strain. It is necessary to remove all particles of fruits. After that, a little water is added to the decoction to get a glass. Then take before eating
3. Recipe 3. For this decoction you need to take ten grams of dryers, pour boiling water and still heat in a water bath for about fifteen minutes. After the time passed, the decoction must be strain, give it to cool and dilute with boiled water so that it turns out exactly a glass. After the decoction is ready, it needs to be taken at half a cup after each meal
4. Recipe 4. You need to take either the seeds of dill, or the chopped dill itself. Takes about a tablespoon. It is pouring into a glass and pour boiling water. After the decoction was fill, he needs to drink throughout the day when the attack occurred
5. Recipe 5 You need to take five grams of nettle flowers, pour it with 200 milliliters boiling water. After the decoction cooled, you need to take half a glass twice a day

There are many decoction recipes, thanks to which a person can significantly improve his well-being. In addition, each of them is very easy to cook, you do not need to run around the pharmacies and look for the necessary grass. Everything is within walking distance, and you can buy it in any pharmacy.

Folk remedies. Horseradish

There are several most effective folk remedies in the treatment of IBS. This refers to hell. Many people may seem, what benefit from this plant, because it is customary to add it to the twist or to eat, refueling them with dishes.

But in fact, Khrena has a lot healing propertiesThanks to which it is used in the treatment of IBS.

There are three most popular recipes, which contains horseradish:

1. Recipe 1. It is necessary to take the root of the horse, about five grams, and it is smaller as fashionable. After that, the resulting mixture is poured a quarter of liters of boiling water and overflows to thermos. The decoction should stand at least three hours in order to brew better. After it is ready, it is necessary to carry out inhalation
2. Recipe 2. You need to take hell, lose it. To take a teaspoon every day and mix it with a teaspoon of honey. In order for the effect to be the most positive, you need to take a mixture of at least one and a half months
3. Recipe 3. You need to take grated horseradish (two tablespoons), pour boiling water and leave for the night. After that, mix with a glass of carrot juice and a glass of honey. Take the mixture every day per hour before meals on a tablespoon

Using horseradish in this form can be significantly improved by heart rhythm, as well as facilitate the state during IBS attacks.

Folk remedies. Hawthorn

Many people have a hawthorn associated only with the tincture, which is sold in pharmacies. That is why, by mistake, this is a berry is not considered useful. This is a huge misconception, since the hawthorn is recommended to use with various heart disease, and not only with IHD.

There are three ways to cook a hawthorn:

• Decoction. You need to take six tablespoons of the berries of the hawthorn and the same dietary. All this is pouring boiling water one and a half liters, wrap in the blanket and leave for a whole day. After this time, the decoction is well fascinated so that there is not a single particle of a hawthorn or mother-in-law, and they use one glad three times a day.
• Infusion. You need to take dry fruits of the hawthorn (tablespoon) and pour them with boiling water. Do it better in the thermos, as it is necessary to give in at least two hours. After the time passed, you need to take three spoons three times a day
• Tea. For tea party lovers, this recipe will have to taste, as tea from the hawthorn is not only useful, but also a fairly pleasant taste. Take berries you need so much so that the color of tea is dark, but not black. For those who love tea with sugar, you can add it there

You can buy a hawthorn in the market at grandmothers, as well as at the autumn time just to ride on the bushes, which are often located next to the height entrances built in about the 70s.

Folk remedies. Fees

Another very much good to a tool During the treatment of IBS is the use of fees. At the heart of such fees there are all herbs that are capable of providing positive influence not only on the heart, but also on the vessels, and also to get rid of cholesterol plaques:

1. Recipe 1. You need to take a white mistletoe and buckwheat flowers. The proportion is two to one. After everything is mixed, you need to take a teaspoon from there and pour it with a glass of boiling water. Then you need to climb into a woolen blanket and leave for the night. Before drinking infusion, it needs to be well strain
2. Recipe 2. The root of corn and lovers to mix in proportion one to one (take about forty-grams). After everything was mixed, you need to pour water and put on fire. Boil approximately eight minutes, and then pour into the thermos, wrap and leave for a while. Before use you need to strain the decoction
3. Recipe 3. You need to take two tablespoons of the horsettle, three tablespoons of a hill, five tablespoons of a hawthorn. All this is mixed and pour a quarter liter boiling water. After that, let stand for about three hours. Before use strain

Many people resort to the treatment of folk remedies after drug preparations did not give proper effect. True, despite the fact that there are many positive feedback on the use of fees, decoction and teas with ischemic heart disease, they need to be treated very carefully, since some people may have individual intolerance to some kind of grass, and resulting in a strong allergic reaction.

Physical exercise

As mentioned above, one of the reasons for the development of the IBS is the lack of physical Loads, Namely a fixed or low-wear lifestyle. Most often it happens in people who are sitting for computer monitors or driving a car.

For people suffering from coronary heart disease, recommended cyclic sports, that is, swimming, running, bike. In addition, it is possible to resort to such only when there is no exacerbation period. Otherwise, it can only aggravate the situation.

For those who have not been detected initial stage Diseases recommended by therapeutic gymnastics, and then only under the supervision of a physiotherapist who can accurately calculate the load, which will benefit, and not harm.

Forecast

Regardless of whether the patient is treated with folk remedies, or resorts only to drugs, there is a prediction that depends on the stage of the disease.

In the event that a person has found initial stage, that is, all the chances of correcting the situation and the preservation of the lifestyle that man lives.

If the disease was discovered in the third or fourth stage, the risk of infarction increases, which at best may hit the entire myocardial area.

But at the fourth stage, the patients are most often dying from the extensive myocardial infarction, as, even completely changing the diet and observing all the recommendations, the disease struck the large portion of the heart.

Treatment of IBS by folk remedies today is not uncommon. And besides, many cardiac doctors themselves offer to accept one or another decoction to maintain good well-being and additional assistance to medicines.

Modern methods of treatment of ischemic heart disease

Ischemic heart disease (IBS) is one of the main reasons for the temporary and resistant disability of the population in developed countries of the world. In this regard, the IBS problem takes one of the leading places among the most important medical problems XXI century.

The fate of patients with IHD largely depends on the adequacy of the outpatient treatment, the quality and timeliness of the diagnosis of those clinical forms of the disease that require the provision of the patient emergency care or urgent hospitalization.

Alexander Gorkov, head of the department of X-ray-thrust diagnostics and treatment of the district cardiological dispensary (Surgut, KhMAO - Ugra), told about the modern methods of treatment of ischemic heart disease.

V. Alexander Igorevich, what is IBS?

- Ischemic heart disease is characterized by an absolute or relative violation of myocardial blood supply due to the damage to the coronary arteries of the heart. In other words, myocardia needs more oxygen than it comes with blood. If the IBA manifested itself only by the symptoms of ischemia, it would be enough to constantly take nitroglycerin and not worry about the work of the heart. The term ischemic heart disease includes a number of diseases (arterial hypertension, heart rhythm disorders, heart failure, etc.), which is based on one reason - atherosclerosis of the vessels.

V. Pain in the heart and nitroglycerin - the lot of the people of the older generation?

- Previously it was considered, but now ischemic heart disease does not bypass the younger generation. Many factors of modern reality are assigned to such developments: ecology, hereditary predisposition, lifestyle associated with smoking, hypodynamines and rich diets.

Q. What are the effective methods of treatment of ischemic heart disease appeared in the Arsenal of Cardiologists over the past decades?

- The modern development of technology is accompanied by the improvement of treatment methods, but its main principle remains the same - restoration of blood flow on the narrowed or clogged coronary artery for normal myocardial nutrition. This can be achieved in two ways: drug and surgically.

Medical therapy modern drugs With the proven level of efficiency today is the basic basis for the treatment of chronic IBS. The treatment is aimed at improving the quality of life of the patient, that is, a decrease in the severity of symptoms, preventing the development of such forms of IBS, as a myocardial infarction, unstable angina, sudden heart death.

To do this, in the arsenal of cardiologists there are various drugs that reduce the content of "bad" cholesterol, responsible for the formation of plaques on the walls of the vessels. In addition, drugs are used in the treatment of coronary heart disease, drugs that need to be taken once a day are used: these are antiagregants (dilute blood), antiarrhythmic, antihypertensive and others. It should be noted that only a cardiologist can assign these medicines based on the objective picture of the disease.

With more severe cases, IBS uses surgical treatment methods. Endovascular surgery is considered the most effective method of treating ischemic heart disease. This is a relatively young direction of medicine has already gained strong position in the treatment of IBS. All interventions are carried out without cuts, through a puncture under X-ray observation. These features are important to those patients who are contraindicated (due to concomitant diseases or general weakening of the organism) traditional surgical intervention.

From the methods of endovascular surgery with IHD, balloon angioplasty and stenting are used, which allow to restore the permeability in the arteries affected by ischemia. The essence of the method is that a special cylinder is introduced into the vessel, then he is swelling and "moves" atherosclerotic plaques or blood clocks to the sides. After that, the artery is set by a cylindrical wall (wire design of a special alloy), which is capable of retaining a given vessel shape.

Generally accepted I. effective techniques Operational blood flow in a narrowed or clogged artery is the operation of the Aorticorial shunting, when the artery is blocked or a thrombus of the artery is replaced by an "artificial vessel", which takes on the conduct of blood flow. These operations are almost always performed on a non-working heart under conditions of artificial blood circulation, for which there are clear indications.

Nevertheless, the positive effect after surgical and endovascular treatment is stable and long.

V. Alexander Igorevich, what is the reason for choosing the method used?

- human health state, degree of damage to coronary arteries atherosclerotic plaques or blood closures, and one of the important indicators is time! As part of the effective work in the KhMAO - Ugra, the Ugra Cor project project, patients from the entire district in the first hours from the beginning owl syndrome In one of the three cents of interventional cardiology, including the district cardiological dispensary, and doctors have time to assist with the use of surgical maloveraumatic methods. In 2012, in the cardiocenter, about 1,100 angioplasty operations were performed, about 300 of them - patients with acute coronary syndrome in the framework of the Ugra Cor project.

V. Alexander Igorevich, tell us how to change the life of a person with a diagnosis of ischemic heart disease?

- Treatment of IBS suggests joint work Cardiologist and patient in several directions. First of all, it is necessary to take care of changing the style of life and the impact on the risk factors of ischemic heart disease. This is a refusal of smoking, cholesterol level correction with diet or drugs. Highly an important point non-drug treatment IHD is the struggle with a sedentary way of life by increasing physical activity patient. And, of course, the preliminary treatment of concomitant diseases, if the development of IBS occurs on their background.

Modern methods for the treatment of ischemic heart disease are effectively helping people to live a better and long life. But health is the daily result of human labor over himself. Direct your strength to keep your own health and take care of your heart health!

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CDP treatment, assumes the collaboration of the cardiologist and the patient immediately in several directions. First of all, you need to take care of changing the style of life. In addition, drug treatment is appointed, and if necessary, surgical treatment methods are used.

Changing the lifestyle and neutralization of risk factors include mandatory smoking, correction of cholesterol levels (with a diet or drugs), a decrease in body weight. The so-called "Mediterranean diet" is recommended for patients with "Mediterranean diet", which includes vegetables, fruits, light dishes from birds, fish and seafood.

A very important point of non-drug treatment of IBS is the struggle with a sedentary way of life by increasing the physical activity of the patient. Of course, an indispensable condition for the successful treatment of IBS is pre-treatment from hypertension or diabetes, if the development of IBS occurs against the background of these diseases.

The objectives of the treatment of ischemic heart disease are defined as an improvement in the quality of life of the patient, that is, a decrease in the severity of symptoms, preventing the development of such forms of IBS, as a myocardial infarction, unstable angina, sudden cardiac death, as well as an increase in the life expectancy of the patient. The initial relocation of the attack of angina is carried out with the help of nitroglycerin, which has a vasodilatory action. The rest of the drug treatment of ischemic heart disease is prescribed only a cardiologist, based on the objective picture of the disease. Among the drugs that are used in the treatment of IBS, drugs can be distinguished by drugs that contribute to the reduction of the need of myocardium in oxygen, an increase in the volume of the coronary channel, etc. However, the main task in the treatment of IBS is to free the overlap vessels - using medications is practically not solved (in particular, sclerotic plaques are practically not destroyed by medicines). In serious cases, the operation will be required.

Aspirin was considered a classic tool with a classic agent for many years, many cardiologists even recommend applying it prophylactically in small quantities (half / one fourth tablet per day).

The modern level of cardiology has a varied arsenal of medicines aimed at treating various forms of IBS. However, any medicines can only assign a cardiologist and can only be applied under the control of the doctor.

With more severe cases, IBS uses surgical treatment methods. Pretty nice results Shows coronary shunting, when the artery is blocked or a thrombus, the artery is replaced by an "artificial vessel", which takes on the conduct of blood flow. These operations are almost always performed on a non-working heart with artificial blood circulation, after shunting the patient accounts for a long time to restore from extensive operating injury. The shunting method has a lot of contraindications, especially in patients with a weakened organism, but successful holding Operations results are usually good.

The most promising method of treating IBS on currently Endovascular surgery (X-ray mergery) is considered. The term "endovascular" is translated as "inside the vessel". This is a relatively young direction of medicine has already gained strong position in the treatment of IBS. All interventions are conducted without cuts, through punctures in the skin, under X-ray observation, to carry out enough local anesthesia. All these features are most important in the sick, for whom, due to concomitant diseases, or due to the overall weakening of the body, traditional surgical intervention is contraindicated. From the methods of endovascular surgery, the IWC is most often used balloon angioplasty and stenting, which allow to restore the permeability in the arteries affected by ischemia. When using balloon angioplasty, a special cylinder is introduced into the vessel, and then he is inflated and "moves" at the side atherosclerotic plaques or blood clocks. After that, the so-called stent is introduced into the artery - the mesh tubular frame from the "medical" stainless steel or alloys of biologically inert metals, capable of independently expanding and maintaining a given vessel shape.

Treatment of ischemic heart disease, primarily depends on clinical form. For example, although stenasia and myocardial infarction uses some general principles of treatment, nevertheless, the treatment tactics, the selection of activity and specific drugs can differ dramatically. However, you can highlight some general areasImportant for all forms of IBS.

• 1. Restriction of exercise. At physical activity, the load on myocardium increases, and as a result of this, the need of myocardium in oxygen and nutrients. If the myocardial blood supply is violated, this need is unsatisfied, which actually leads to the manifestations of IBS. Therefore, the most important component of treating any form of IBS is the restriction of physical exertion and gradual increases of it during rehabilitation.
• 2. Diet. With IHD in order to reduce the load on myocardium in the diet, we restrict the reception of water and sodium chloride ( crash salt). In addition, given the importance of atherosclerosis in pathogenesis IBS, much attention It is paid to the restriction of products that contribute to the progression of atherosclerosis. An important component of treating IHD is the fight against obesity as a risk factor.

It should be limited, or if possible, refuse from the following groups of products.

• · Animal fats (fat, butter, fatty meat varieties)
• · Fried and smoked food.
• · Products containing a large amount of salt (salted cabbage, salt fish, etc.)
• · Restrict the reception of high-calorie food, especially fast suction carbohydrates. (chocolate, candy, cakes, dough).

To correct body weight, it is especially important to monitor the ratio of energy coming with eaten food, and energy consumption as a result of the body's activities. For a stable weight loss, the deficit should be at least 300 kilocalories daily. On average, a person who is not engaged in physical work in a day spends 2000--2500 kilocalories.

3. Pharmacotherapy with IHS.There are a number of groups of drugs that can be shown to use with one form or another CHD. In the US, there is a formula for treating IBS: "A-B-C". It implies the use of the triads of drugs, namely antiagregants, in-adrenoblockers and hypocholesterolemic drugs.

Also, in the presence of related hypertension, it is necessary to ensure the achievement of target levels of arterial pressure.

• - Antiagregants (a). Antiagregants prevent platelet aggregations and red blood cells, reduce their ability to gluing and sticking to the endothelium of blood vessels. Antiagregants facilitate the deformation of erythrocytes when passing through the capillaries, improve blood flow.
• · Aspirin - accepted 1 time per day at a dose of 100 mg, with suspected development of myocardial infarction, a single dose can reach 500 mg.
• · Clopidogrel - accepted 1 time per day 1 tablet 75 mg. Received within 9 months after the completion of endovascular interventions and AKSH.
• - B-adrenoblocators (B). Due to the action on B-ArenoPraztors, adrenoblockers reduce the heart rate and, as a result, consumption of oxygen myocardium. Independent randomized studies confirm an increase in life expectancy in adrenoblator receptions and reducing the frequency of cardiovascular events, including repeated. Currently, it is inappropriate to use the preparation of Atenolol, since according to randomized research, it does not improve the forecast. B-adrenobloclars are contraindicated with accompanying light pathology, bronchial asthma, COPD. Below are the most popular in-adrenoblays with proven properties of improving forecast with IHD.
• · Metoprolol (Betalok Zok, Betalki, Egilov, Methodographer, Vazocardin);
• · Bisoprolol (Concorp, Coronal, Bisogamma, Biprol);
• · Carvedilol (dilatrend, Talliton, Coriol).
• - Statins and Fibrats (C). Cholesterol drugs are applied to reduce the rate of development of existing atherosclerotic plaques and preventing new ones. A positive effect on life expectancy has been proven, these drugs also reduce the frequency and severity of cardiovascular events. The target level of cholesterol in patients with IHD should be lower than those without IHD, and is 4.5 mmol / l. Target Level of LDL in patients with IBS - 2.5 mmol / l.
• · Lovastatin;
• · Simvastatin;
• · Atorvastatin;
• · Rosavastatin (the only drug, reliably reducing the size of atherosclerotic plaques);

Fibrats. The class of drugs that increase the anti-theaterogenic fraction of HDL, with a decrease in which mortality from IBS increases. Applied to the treatment of dyslipidemia IIA, IIB, III, IV, V. differ from the statins by the fact that they mainly reduce triglycerides (LPONP) and may increase the PLP fraction. Statins mainly reduce LDL and do not provide meaningful influence on LPONP and HDL. Therefore, for the maximum effective treatment of macrovascular complications, a combination of statins and fibrats is required. With the use of fenofibrate, the mortality from IBS decreases by 25%. From fibrats, only fenofibrate is safely combined with any classes of statins (FDA).

· Fenofibrat.

Other classes: Omega-3-polyunsaturated fatty acids (omakor). The CDC is used to reduce the phospholipid layer of the cardiomyocyte membrane. Restoring the structure of the omakor cardiomyocythic membrane restores the main (life) functions of the sedz cells - the conductivity and the reduction, which were violated as a result of myocardial ischemia.

Nitrates.There are nitrates for injecting administration.

Preparations of this group are derivatives of glycerol, triglycerides, diglycerides and monoglycerides. The mechanism of action lies in the effect of nitro group (NO) on contractile activity Smooth vessel muscles. Nitrates mainly act on the venous wall, reducing the preload on myocardium (by expanding the vessels of the venous bed and blood deposition). The side effect of nitrate is to reduce blood pressure and headaches. Nitrates are not recommended for arterial pressure below 100/60 mm Hg. Art. In addition, it is currently reliably known that the reception of nitrates does not improve the prediction of patients with IBS, that is, does not lead to an increase in survival, and is currently used as a drug to relieve the symptoms of angina. Intravenous drip administration of nitroglycerin, allows you to effectively deal with angina phenomena, mainly against the background of high blood pressure numbers.

Nitrates exist both in injecting and in tablet forms.

• · Nitroglycerin;
• · Isosorbide mononitrate.

Anticoagulants.Anticoagulants inhibit the appearance of fibrin yarns, they impede the formation of thrombus, contribute to the cessation of the growth of the three-bodies that have already arisen, strengthen the effects of endogenous enzymes that destroy fibrin.

· Heparin (the mechanism of action is due to its ability to specifically bind to antithrombin III, which dramatically increases the inhibitory effect of the latter with respect to thrombin. As a result, the blood is folded slower).

Heparin is introduced under the skin of the abdomen or with the help of infusomat intravenously. Myocardial infarction is an indication for the purpose of the heparinocylactic thrombov, heparin is prescribed at a dose of 12,500 me, is introduced under the skin of the abdomen daily for 5-7 days. In the conditions of Orit, heparin is introduced by a patient with the help of infusoma. The instrumental criterion for the purpose of the heparin is the presence of the depression of the S-T segment on the ECG, which indicates acute process. This feature Important in plan differential diagnosisFor example, in cases where the patient has ECG signs of previously infarction events.

Diuretics.Diuretic products are designed to reduce the load on myocardium by reducing the amount of circulating blood due to the accelerated removal of the fluid from the body.

Loop.Preparation "Furosemid" in tablet form.

The loop diuretics reduce the reabsorption of Na +, K +, Cl - in the thick ascending part of the loop of Genla, thereby reducing reabsorption ( reverse suction) water. Posses are quite pronounced fast actionAs a rule, applied as emergency preparations (for the implementation of forced diuresis).

The most common drug in this group is Furosemide (Laziks). There is in injecting and tablet forms.

Tiazid.Tiazide diuretic belong to Ca 2+ saving diuretics. Reducing the reabsorption of Na + and Cl - in the thick segment of the rising part of the loop of the gene and the initial separation of the dystal tube of nephron, thiazide drugs reduce urine reabsorption. With systematic reception of drugs of this group, the risk of cardiovascular complications is reduced in the presence of a concomitant hypertensive disease.

• · Hypothiazide;
• · Indapamide.

Inhibitors of angiotensin-converting enzyme.Acting on an angiotensin-converting enzyme (ACE), this group of drugs blocks the formation of angiotensin II from angiotensin I, thus preventing the implementation of angiotensin II effects, that is, leveling spasms of vessels. This ensures the maintenance of target figures of blood pressure. Preparations of this group have a nephro- and cardioprotective effect.

• · Enalapril;
• · Lysinopril;
• · Captive.

Antiarrhythmic drugs.Amyodaron preparation is available in tablet form.

· Amiodaron refers to the III group of antiarrhythmic drugs, has an integrated antiarrhythmic effect. This drug acts on Na + and K + channels of cardiomyocytes, and also blocks B - and B-adrenoreceptors. Thus, amiodaron has an anti-infanal and antiarrhythmic effect. According to randomized clinical studies, the drug increases the life expectancy of patients, regularly accepting it. When receiving tablet forms of amiodarone, the clinical effect is observed approximately 2-3 days. The maximum effect is achieved in 8-12 weeks. This is associated with a long period of semi-anniversary of the drug (2-3 months). Concerning this drug It is used in the prevention of arrhythmias and is not a means of emergency assistance.

Taking into account these properties of the drug, the following scheme of its application is recommended. During the saturation period (the first 7-15 days), amiodarone is prescribed in a daily dose of 10 mg / kg of patient weight in 2-3 reception. With the onset of a persistent antiarrhythmic effect, confirmed by the results of daily ECG-monitoring, the dose is gradually reduced by 200 mg every 5 days before the maintenance dose of 200 mg per day is reached.

Other groups of drugs.

· Ethylmethylhydroxypyridine

Preparation "Mexidol" in tablet form. Metabolic cytoprotector, antioxidant antihypoxant, which has a comprehensive effect on key stones of pathogenesis cardiovascular diseases: Antiaterosclerotic, anti-chemic, membrancial. Theoretically ethylmethylhydroxypyridine succinate has a significant positive effect, but at present, data on its clinical efficacy, based on independent randomized placebo-controlled studies, no.

• · Mexicor;
• · Coronaters;
• · Trimetazidine.
• 4. Use of antibiotics with IHD.There are results of clinical observations of the comparative efficiency of two different courses of antibiotics and placebo in patients who entered the hospital or with acute infarction Myocardial, or with unstable angina. Studies have shown the effectiveness of a number of antibiotics in the treatment of IBS. The effectiveness of this type of therapy pathogenetically not justified, and this technique is not included in the CHA treatment standards.
• 5. Endovascular coronaugorangioplasty.The use of endovascular (forcetable, transluminal) interventions (coronaugioplasty) is developing under various IBS forms. These interventions include balloon angioplasty and stenting under the control of coronary angiography. At the same time, the tools are introduced through one of the major arteries (in most cases the femoral artery is used), and the procedure is performed under control of x-ray. In many cases, such interventions help prevent the development or progression of myocardial infarction and avoid open operational intervention.

The individual area of \u200b\u200bcardiology is engaged in this direction of treatment of CDS - interventional cardiology.

6. Surgical treatment.

Conducts aorto-coronary shunting.

With certain parameters of coronary heart disease, testimony arise to coronary shunting - operation at which the blood supply to myocardium is improved by connecting the coronary vessels below their place of lesion with external vessels. The most famous aorticoronary shunting (AKSH), in which the aorta is connected to the coronary arteries segments. For this, autotransplants are often used as shunts (usually a large subcutaneous vein).

It is also possible to use balloon dilatation of vessels. Under this operation, the manipulator is introduced into the coronary vessels through the artery puncture (usually femoral or radial), and through a cylinder filled with a contrast agent, an extension of the vessel lumen is performed, the operation is, in fact, the burning of coronary vessels. Currently, "clean" balloon angioplasty without subsequent implantation of the stent is practically not used, due to low efficiency in the remote period.

• 7. Other non-drug treatment methods
• - Hirudotherapy.Hirudotherapy is a method of treatment based on the use of antiagregated properties of saliva leech. This method is alternative and did not take clinical trials for compliance with the requirements of evidence-based medicine. Currently, Russia is relatively rare, not included in the standards for the provision medical care With IHD, applies, as a rule, at the request of patients. Potential positive effects This method is concluded in the prevention of thrombosis. It is worth noting that in the treatment according to the approved standards, this task is performed using heparofilax.
• - The method of shock-wave therapy.The effect of low-power shock waves leads to myocardial revascularization.

An extracorporeal source of a focused acoustic wave allows you to remotely affect the heart, causing "therapeutic angiogenesis" (vesa formation) in the zone of myocardial ischemia. The impact of UVT has a double effect - short-term and long-term. First, the vessels are expanding, and the blood flow is improving. But the most important thing begins later - in the area of \u200b\u200bthe defeat, new vessels arise, which are already providing a long-term improvement.

Low-intensity shock waves cause shift voltage in the vascular wall. This stimulates the release of vascular growth factors, launching the growth process of new vessels, feeding the heart, improve myocardial microcirculation and reducing angina phenomena. The results of such treatment theoretically is to reduce the functional class of angina, an increase in the tolerance of physical activity, reducing the frequency of attacks and drug needs.

However, it should be noted that at present, adequate independent multicenter ranked studies assessing the effectiveness of this technique were not carried out. Studies referred to as evidence of the effectiveness of this technique are usually produced by the companies themselves manufacturers. Or do not correspond to the criteria of evidence-based medicine.

This method did not receive widespread in Russia due to dubious efficacy, high cost of equipment, and the absence of relevant specialists. In 2008, these method did not enter the IHD medical care standard, and the execution of data of manipulations was carried out on a contractual commercial basis, or in some cases under voluntary health insurance agreements.

- The use of stem cells.When using stem cells, the procedure performs calculate that polypotent stem cells introduced into the patient's body are differentiated into the missing cells of myocardium or the adventitization of vessels. It should be noted that stem cells actually possess this ability, but at present the level modern technologies It does not allow differentiate polypotent cell into the cloth we need. The cell itself makes the choice of the differentiation path - and often not the one that is needed for the treatment of IBS.

This treatment method is promising, but so far the clinical approbation has not passed and does not meet the criteria of evidence-based medicine. Requires years scientific researchTo ensure that the effect that is expected by patients from the administration of polypotent stem cells.

Currently, this treatment method is not used in official medicine And it is not included in the provision of assistance with IHD.

- CHA quantum therapy.It is therapy by exposure to laser radiation. The effectiveness of this method has not been proven, an independent clinical study was conducted.

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 last years It appeared evidence that the addition of mildronate cytoprotective effects to anti-infanal therapy or trimethazidia can enhance the anti-aishemic effect of antiagonal 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 when 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

Relatively low-active patients with moderately pronounced angina, especially in old age, it is often sufficient to recommend the reception of nitroglycerin in cases where the attack does not pass independently after stopping the load for 2-3 minutes and / or preventive reception Isosorbide 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 in the appointment of antianginal preparations 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 is a very good forecast, the basis medical events 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 maximum doses 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 inclinations to spastic reactions and long-term remission is observed in patients with an isolated spontaneous angina, without concomitant stress angina (in patients with normal or low-changed 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 estimating the effectiveness of the appointment of 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.

Treatment of ischemic heart disease, primarily depends on clinical form. For example, although stenasia and myocardial infarction uses some general principles of treatment, nevertheless, the treatment tactics, the selection of activity and specific drugs can differ dramatically. However, some general directions are allocated for all forms of IBS.

1. Restriction of physical exertion. At physical activity, the load on myocardium increases, and as a result of this, the need of myocardium in oxygen and nutrients. If the myocardial blood supply is violated, this need is unsatisfied, which actually leads to the manifestations of IBS. Therefore, the most important component of treating any form of IBS is the restriction of physical exertion and gradual increases of it during rehabilitation.

2. Diet. With IHD, in order to reduce the load on myocardium in the diet, we limit the reception of water and sodium chloride (sodium salt). In addition, given the importance of atherosclerosis in the PAT Pathogenesis, much attention is paid to the restriction of products that contribute to the progression of atherosclerosis. An important component of treating IHD is the fight against obesity as a risk factor.

It should be limited, or if possible, refuse from the following groups of products.

Animal fats (fat, butter, fatty meat varieties)

Fried and smoked food.

Products containing a large amount of salt (salted cabbage, salt fish, etc.)

Restrict the reception of high-calorie food, especially fast suction carbohydrates. (chocolate, candy, cakes, dough).

To correct body weight, it is especially important to monitor the ratio of energy coming with eaten food, and energy consumption as a result of the body's activities. For a stable weight loss, the deficit should be at least 300 kilocalories daily. On average, a person who is not engaged in physical work in a day spends 2000-2500 kokalorius.

3. Pharmacotherapy with IHS. There are a number of groups of drugs that can be shown to use with one form or another CHD. In the US, there is a formula for treating IBS: "A-B-C". It implies the use of the triads of drugs, namely antiagregants. -Adrenoblockers and hypocholesterolemic drugs.

Also, in the presence of related hypertension, it is necessary to ensure the achievement of target levels of arterial pressure.

- Antiagregants (a). Antiagregants prevent platelet aggregations and red blood cells, reduce their ability to gluing and sticking to the endothelium of blood vessels. Antiagregants facilitate the deformation of erythrocytes when passing through the capillaries, improve blood flow.

Aspirin is taken 1 time per day at a dose of 100 mg, if the development of myocardial infarction is suspected, a one-time dose can reach 500 mg.

Clopidogrel - accepted 1 time per day 1 tablet 75 mg. Received within 9 months after the completion of endovascular interventions and AKSH.

-? -Adrenoblocators (B). Due to the action on? -Aarteroreceptors, adrenoblockers reduce the heart rate and, as a result, consumption of oxygen myocardium. Independent randomized studies confirm an increase in life expectancy when receiving? -Adrenoblocators and a decrease in the frequency of cardiovascular events, including repeated. Currently, it is inappropriate to use the preparation of Atenolol, since according to randomized research, it does not improve the forecast. -Adrenoblocators are contraindicated with accompanying light pathology, bronchial asthma, COPD. Below are the most popular? -Adrenoblays with proven properties of improving forecasting with IHD.

Metoprolol (Betalok Zok, Betalok, Egilov, Metokard, Vazocardin);

Bisoprolol (Concorp, Coronal, Bisogamma, Biprol);

Carvedilol (dilatrend, Talliton, Coriol).

- Statins and Fibrats (C). Cholesterol drugs are applied to reduce the rate of development of existing atherosclerotic plaques and preventing new ones. A positive effect on life expectancy has been proven, these drugs also reduce the frequency and severity of cardiovascular events. The target level of cholesterol in patients with IHD should be lower than those without IHD, and is 4.5 mmol / l. Target Level of LDL in patients with IBS - 2.5 mmol / l.

Lovastatin;

Simvastatin;

Atorvastatin;

Rosavastatin (the only drug, reliably reducing the size of atherosclerotic plaques);

Fibrats. The class of drugs that increase the anti-theaterogenic fraction of HDL, with a decrease in which mortality from IBS increases. Applied to the treatment of dyslipidemia IIA, IIB, III, IV, V. differ from the statins by the fact that they mainly reduce triglycerides (LPONP) and may increase the PLP fraction. Statins mainly reduce LDL and do not provide significant effect on LPONP and HDL. Therefore, for the maximum effective treatment of macrovascular complications, a combination of statins and fibrats is required. With the use of fenofibrate, the mortality from IBS decreases by 25%. From fibrats, only fenofibrate is safely combined with any classes of statins (FDA).

Fenofibrat.

Other classes: Omega-3-polyunsaturated fatty acids (omakor). The CDC is used to reduce the phospholipid layer of the cardiomyocyte membrane. Restoring the structure of the omakor cardiomyocythic membrane restores the main (life) functions of the sedz cells - the conductivity and the reduction, which were violated as a result of myocardial ischemia.

Nitrates. There are nitrates for injecting administration.

Preparations of this group are derivatives of glycerol, triglycerides, diglycerides and monoglycerides. The mechanism of action lies in the influence of the nitro group (NO) on the contractile activity of the smooth muscles of the vessels.

Nitrates mainly act on the venous wall, reducing the preload on myocardium (by expanding the vessels of the venous bed and blood deposition). The side effect of nitrate is to reduce blood pressure and headaches. Nitrates are not recommended for arterial pressure below 100/60 mm Hg. Art. In addition, it is currently reliably known that the reception of nitrates does not improve the prediction of patients with IBS, that is, does not lead to an increase in survival, and is currently used as a drug to relieve the symptoms of angina. Intravenous drip administration of nitroglycerin, allows you to effectively deal with angina phenomena, mainly against the background of high blood pressure numbers.

Nitrates exist both in injecting and in tablet forms.

Nitroglycerine;

Isosorbide mononitrate.

Anticoagulants. Anticoagulants inhibit the appearance of fibrin yarns, they impede the formation of thrombus, contribute to the cessation of the growth of the three-bodies that have already arisen, strengthen the effects of endogenous enzymes that destroy fibrin.

Heparin (the mechanism of action is due to its ability to specifically bind to antithrombin III, which sharply increases the inhibitory effect of the latter in relation to thrombin. As a result, the blood is folded slower).

Heparin is introduced under the skin of the abdomen or with the help of infusomat intravenously. Myocardial infarction is an indication for the purpose of the heparinocylactic thrombov, heparin is prescribed at a dose of 12,500 me, is introduced under the skin of the abdomen daily for 5-7 days. In the conditions of Orit, heparin is introduced by a patient with the help of infusoma. The instrumental criterion for the purpose of the heparin is the presence of depression of the S-T segment on the ECG, which indicates an acute process. This feature is important in terms of differential diagnostics, for example, in cases where the patient has ECG signs of previously occurring infarction.

Diuretics. Diuretic products are designed to reduce the load on myocardium by reducing the amount of circulating blood due to the accelerated removal of the fluid from the body.

Loop. Preparation "Furosemid" in tablet form.

Loop diuretics reduce the reabsorption of Na +, K +, Cl- in the thick ascending part of the loop of Genla, thereby reducing the reabsorption (reverse absorption) of water. They have a fairly pronounced rapid effect, usually apply as emergency preparations (for the implementation of forced diuresis).

The most common drug in this group is Furosemide (Laziks). There is in injecting and tablet forms.

Tiazid. Tiazide diuretic belongs to Ca2 + saving diuretics. Reducing the reabsorption of Na + and Cl- in the thick segment of the rising part of the loop of the gene and the initial separation of the dumpan tube of nephron, thiazide preparations reduce urine reabsorption. With systematic reception of drugs of this group, the risk of cardiovascular complications is reduced in the presence of a concomitant hypertensive disease.

Hypothiazide;

Indapamide.

Inhibitors of angiotensin-converting enzyme. Acting on an angiotensin-converting enzyme (ACE), this group of drugs blocks the formation of angiotensin II from angiotensin I, thus preventing the implementation of angiotensin II effects, that is, leveling spasms of vessels. This ensures the maintenance of target figures of blood pressure. Preparations of this group have a nephro- and cardioprotective effect.

Enalapril;

Lysinopril;

Captive.

Antiarrhythmic drugs. Amyodaron preparation is available in tablet form.

Amiodaron refers to the III group of antiarrhythmic drugs, has an integrated antiarrhythmic effect. This drug acts on Na + and K + Cardiomyocyte channels, and also blocks? - And? -Adrenoreceptors. Thus, amiodaron has an anti-infanal and antiarrhythmic effect. According to randomized clinical studies, the drug increases the life expectancy of patients, regularly accepting it. When receiving tablet forms of amiodarone, the clinical effect is observed approximately 2-3 days. The maximum effect is achieved in 8-12 weeks. This is associated with a long period of semi-anniversary of the drug (2-3 months). In this regard, this drug is applied in the prevention of arrhythmias and is not a means of emergency.

Taking into account these properties of the drug, the following scheme of its application is recommended. During the saturation period (the first 7-15 days), amiodarone is prescribed in a daily dose of 10 mg / kg of patient weight in 2-3 reception. With the onset of a persistent antiarrhythmic effect, confirmed by the results of daily ECG-monitoring, the dose is gradually reduced by 200 mg every 5 days before the maintenance dose of 200 mg per day is reached.

Other groups of drugs.

Ethylmethylhydroxypyridine

Preparation "Mexidol" in tablet form. Metabolic cytoprotector, antioxidant-antihypoxant, which has a complex effect on key structures of cardiovascular diseases: anti-seaterosclerotic, anti-chemic, membrancial. Theoretically ethylmethylhydroxypyridine succinate has a significant positive effect, but at present, data on its clinical efficacy, based on independent randomized placebo-controlled studies, no.

Mexicor;

Coronators;

Trimetazidine.

4. Use of antibiotics with IHD. There are results of clinical observations of the comparative efficiency of two different antibiotics and placebo courses in patients who entered the hospital or with acute myocardial infarction, or with unstable angina. Studies have shown the effectiveness of a number of antibiotics in the treatment of IBS.

The effectiveness of this type of therapy pathogenetically not justified, and this technique is not included in the CHA treatment standards.

5. Endovascular coronaugorangioplasty. The use of endovascular (forcetable, transluminal) interventions (coronaugioplasty) is developing under various IBS forms. These interventions include balloon angioplasty and stenting under the control of coronary angiography. At the same time, the tools are introduced through one of the major arteries (in most cases the femoral artery is used), and the procedure is performed under control of x-ray. In many cases, such interventions help prevent the development or progression of myocardial infarction and avoid open operational intervention.

The individual area of \u200b\u200bcardiology is engaged in this direction of treatment of CDS - interventional cardiology.

6. Surgical treatment.

Conducts aorto-coronary shunting.

With certain parameters of coronary heart disease, testimony arise to coronary shunting - operation at which the blood supply to myocardium is improved by connecting the coronary vessels below their place of lesion with external vessels. The most famous aorticoronary shunting (AKSH), in which the aorta is connected to the coronary arteries segments. For this, autotransplants are often used as shunts (usually a large subcutaneous vein).

It is also possible to use balloon dilatation of vessels. Under this operation, the manipulator is introduced into the coronary vessels through the artery puncture (usually femoral or radial), and through a cylinder filled with a contrast agent, an extension of the vessel lumen is performed, the operation is, in fact, the burning of coronary vessels. Currently, "clean" balloon angioplasty without subsequent implantation of the stent is practically not used, due to low efficiency in the remote period.

7. Other non-drug treatment methods

- Gillotherapy. Hirudotherapy is a method of treatment based on the use of antiagregated properties of saliva leech. This method is alternative and did not take clinical trials for compliance with the requirements of evidence-based medicine. Currently, Russia is used relatively rarely, not included in the standards for providing medical care for IHD, it is applied, as a rule, at the request of patients. The potential positive effects of this method are concluded in the prevention of thrombosis. It is worth noting that in the treatment according to the approved standards, this task is performed using heparofilax.

- The method of shock-wave therapy. The effect of low-power shock waves leads to myocardial revascularization.

An extracorporeal source of a focused acoustic wave allows you to remotely affect the heart, causing "therapeutic angiogenesis" (vesa formation) in the zone of myocardial ischemia. The impact of UVT has a double effect - short-term and long-term. First, the vessels are expanding, and the blood flow is improving. But the most important thing begins later - in the area of \u200b\u200bthe defeat, new vessels arise, which are already providing a long-term improvement.

Low-intensity shock waves cause shift voltage in the vascular wall. This stimulates the release of vascular growth factors, launching the growth process of new vessels, feeding the heart, improve myocardial microcirculation and reducing angina phenomena. The results of such treatment theoretically is to reduce the functional class of angina, an increase in the tolerance of physical activity, reducing the frequency of attacks and drug needs.

However, it should be noted that at present, adequate independent multicenter ranked studies assessing the effectiveness of this technique were not carried out. Studies referred to as evidence of the effectiveness of this technique are usually produced by the companies themselves manufacturers. Or do not correspond to the criteria of evidence-based medicine.

This method did not receive widespread in Russia due to dubious efficacy, high cost of equipment, and the absence of relevant specialists. In 2008, these method did not enter the IHD medical care standard, and the execution of data of manipulations was carried out on a contractual commercial basis, or in some cases under voluntary health insurance agreements.

- The use of stem cells. When using stem cells, the procedure performs calculate that polypotent stem cells introduced into the patient's body are differentiated into the missing cells of myocardium or the adventitization of vessels. It should be noted that stem cells actually have this ability, but at present the level of modern technologies does not allow differentiate polypotent cell into the cloth we need. The cell itself makes the choice of the differentiation path - and often not the one that is needed for the treatment of IBS.

This treatment method is promising, but so far the clinical approbation has not passed and does not meet the criteria of evidence-based medicine. The years of scientific research are required to ensure that the effect of patients from the administration of polypotent stem cells.

Currently, this method of treatment is not used in official medicine and is not included in the Assistance Standard for CHA.

- CHA quantum therapy. It is therapy by exposure to laser radiation. The effectiveness of this method has not been proven, an independent clinical study was conducted.

Modern aspects of medication treatment of chronic chronic IHD

In recent years, the ideas about the mechanisms of development of atherosclerosis and chronic IBS have significantly expanded and significant progress occurred in the field of drug treatment of these patients. To date, 2 directions in the treatment of chronic IBS are distinguished: 1. Improving life forecast; 2. Improving the quality of life of the patient: a decrease in the attacks of angina and myocardial ischemia, an increase in the portability of physical exertion. But it becomes more and more obvious that in the early stages therapeutic effects Extremely important is the impact on the prevention of damage to the vascular wall (atherosclerosis) by the maximum full modification of the risk factors (1).

Authors:

Medicinal preparations that improve the forecast in patients of chronic IBS

Mandatory treatment of patients with chronic IBS are antitrombocytic drugs (antiagrams) (acetylsalicylic acid - ASK, clopidogrel). Aspirin remains the basis for the prevention of arterial thrombosis, is shown at a dose of 75-150 mg / day. Its influence on the degree of vascular risk is demonstrated in a number of large-scale controlled studies. Thus, the risk of myocardial infarction in patients with stable angina decreased by an average of 87% with a long-term (up to 6 years) ASK reception. After myocardial infarction, mortality decreases by 15%, the frequency of development of the myocardial re-infarction is 31%. Long-term use of antiagregants is justified in all patients who do not have obvious contraindications to these drugs - peptic disease Stomach, blood system diseases, hypersensitivity, etc. Additional safety is provided by the preparations of acetylsalicylic acid coated with an intestinal-soluble shell, or antacids (magnesium hydroxide). Clopidogrel (Non-specific ADF receptor blocker) is an alternative to ASC, does not directly effect on the gastric mucous membrane and dyspeptic symptoms causes. But the joint use of gastric secretion inhibitors (Ezomeprazole) and ASK (80 mg / day) is more efficient in the prevention of repeated ulcerative bleeding in patients with ulcers than to transfer them to clopidogrel (2). After coronary stenting and in acute coronary syndrome, clopidogrel is used in combination with aspirin for 6-12 months, and with a stable angina charter therapy, two drugs are not substantiated. If you need to receive non-steroidal anti-inflammatory drugs, the aspirin should not be canceled.

Hydolipidemic agents. The most effective at present by hypocholesterolemic means are statins. The indication for the admission of statins in patients with IBC is the presence of hyperlipidemia with an insufficient effect of diet-andotherapy. Along with the hypolipidemic action, they contribute to the stabilization of atherosclerotic plaques, reducing their inclinations to the rupture, improve the endothelial function, to reduce the inclination of the coronary arteries to spastic reactions, suppressing inflammation reactions. Statins have a positive effect on a number of indicators that determine the tendency to thrombosis - blood viscosity, platelet aggregation and erythrocytes, fibrinogen concentration. These drugs reduce the risk of atherosclerotic cardiovascular complications in both primary and secondary prophylaxis. With a stable angina, a decrease in mortality is proved under the influence of Simvastatin (4S, HPS), PPPP, Prosper, Atorvastatin (ASCOT-LLA). The results of the treatment of statins are similar in patients with different levels of serum cholesterol, including "normal". So The solution to the question of treatment with statins depends not only on the level of cholesterol, but also the level of cardiovascular risk. In modern European recommendations, the target level of total cholesterol in patients with IHD and high-risk patients is £ 4.5 mmol / l and HC LDL £ 2.0 mmol / l. Treatment with statins should be carried out constantly, because After one month after the cessation of the drug, the level of blood lipids is returned to the initial one. With the ineffectiveness of reducing the levels of general cholesterol and the LDL hl to the target values \u200b\u200bof the Statin dose increase, observing the interval in 1 month (during this period the greatest effect of the drug is achieved). When using the statins, the level of triglycerides (by 6-12%) is usually somewhat decreased and the level of HDP in the blood plasma increases (by 7-8%). Patients with reduced cholesterol HDL, an increased level of triglycerides having diabetes or metabolic syndrome, shows the appointment of fibrats. It is possible to share the appointment of statins and fibrats (first of all of the fenofibrate), however, it is necessary to regularly monitor the level of KFK in the blood.

β-adrenoblocators. In the absence of contraindications, β-adrenoblockers are prescribed to all patients with IBS, especially after myocardial infarction. The main purpose of therapy is to improve the remote prediction of the patient IDA. β-adrenoblocators significantly improve the prognosis of the life of patients and in the case when the CHA is complicated by heart failure. Obviously, preference should be given to selective β-adrenoblockers (less contraindications and side effects) (Atenolol, metoprolol, bisoprolol, nebivolol, betaxolol), and extensive action drugs. The basic principles of the appointment of β-adrenoblockers consist in maintaining the heart rate within 55-60 blows per minute. In this case, the blockade of β-receptors occurs.

ACE inhibitors. It is well known that the use of ACE inhibitors in patients after a myocardial infarction with signs of heart failure or impaired function of the left ventricle helps to a significant reduction in mortality and the probability of myocardial infarction. Absolute indications for the purpose of the IAPF with chronic IBS are signs of heart failure and a myocardium infarction. In cases of poor tolerance of these drugs, angiotensin receptor antagonists are prescribed (primarily Kandesartan, Walsartan). ACE inhibitors affect the main pathological processes - vasoconstriction, structural changes in the vascular wall, remodeling of the left ventricle, the formation of thrombus underlying the CHD. Protective effect of ACE inhibitors regarding the development of atherosclerosis, apparently due to a decrease in the level of angiotensin II, an increase in nitrogen oxide products, improving the function of the endothelium of vessels. In addition, drugs carry out vasodilation peripheral vessels, as well as coronary arteries, potentiate the effects of nitrovodilators, contributing to the decrease in tolerance to them.

IN lately There were evidence of the effectiveness of some ACE inhibitors in patients with IBS normal function Lz I. arterial pressure. Thus, in the Hope and Europa study, the positive effect of ramipril and perindopoid on the likelihood of cardiovascular complications was demonstrated. But other ACE inhibitors (Quinapril, Trandolapril), respectively, in the studies of Quiet, the PEACE of a clear influence on the course of the CHD did not show (ie, this property is not a class-effect). EUROPA research results (2003) are special attention. According to the results of this study in patients who took perindopril (8 mg) for 4.2 years, the total risk of overall mortality, non-infamary myocardial infarction, unstable angina was reduced by 20%, the number of fatal myocardial infarction - by 24%. Significantly (39%) reduced the need for hospitalization in connection with the development of heart failure. So The use of ACE inhibitors is suitable in patients with angina with arterial hypertension, diabetes mellitus, heart failure, asymptomatic dysfunction of left ventricle or myocardial infarction.

1. Aspirin 75 mg / day in all patients in the absence of contraindications (active gastrointestinal bleeding, allergic to aspirin or its intolerance (a)
2. Statins in all patients with coronary heart disease (a)
3. ACE inhibitors in the presence of arterial hypertension, heart failure, left ventricle dysfunction, transferred myocardial infarction with left ventricle or diabetes dysfunction (a)
4. beta blockers inside patients after myocardial infarction in history or heart failure (a)

1. ACE inhibitors in all patients with angina and a confirmed diagnosis of coronary heart disease (B)
2. Clopidogrel as an alternative to aspirin in patients with stable angina, which cannot take aspirin, for example, due to allergies (B)
3. Statins in high doses in the presence of high risk (cardiovascular mortality of more than 2% per year) in patients with proven coronary heart disease (B)

1. Fibrats at a low level of HDL or high triglyceride content in patients with diabetes mellitus or metabolic syndrome (B).

Note: Class I - reliable evidence and (or) the unity of expert opinions is that this species Treatment is also useful and effective, class IIA - proofs and (or) opinion experts benefit / efficiency, class IIIB - benefit / effectiveness is not well confirmed by evidence and (or) expert opinions.

The level of evidence A: Conditions are obtained in multicenter randomized clinical or method analyzes. The level of evidence in: Creating obtained in one randomized clinical Research or large neranger studies.

Medical therapy aimed at the relief of symptoms of chronic IBS

Modern treatment of IHD includes a number of anti-indian and anti-host drugs and metabolic agents. They are aimed at improving the quality of life of patients by reducing the frequency of angina attacks and eliminate myocardial ischemia. Successful antiagonal treatment is considered in the case of a complete or almost complete elimination of the seizures of angina and the return of the patient to normal activity (angina region not more than I FC) and with minimal side Effects Therapies (3.4). In the treatment of chronic IBS, 3 main groups of drugs are used: β-adrenoblays, organic nitrates, calcium antagonists.

β-adrenoblocators. These drugs are used in chronic IBS in 2 directions: improve the forecast, as mentioned above, and have a pronounced antiagonal effect. Indications for the use of β-adrenoblockers is the presence of angina, especially in combination with arterial hypertension, concomitant heart failure, miraculous myocardial ischemia, myocardial ischemia with concomitant violations heart Rhythm. In the absence of direct contraindications, β-adrenoblastors are prescribed to all patients with IBS, especially after myocardial infarction. In the treatment of β-adrenoblockers, control over hemodynamics is important, achieving target levels of heart rate, if necessary, reduce doses of drugs, but not cancellation in the occurrence of heart rate<60 ударов в минуту. Следует также помнить о возможности развития синдрома отмены, в связи с чем β-адреноблокаторы необходимо отменять постепенно.

Organic nitrates (nitroglycerin preparations, isosorbide of dinitrate and isosorbide 5-mononitrate) are used to prevent angina attacks. These preparations provide hemodynamic unloading of the heart, improve the blood supply to the styled areas and increases tolerance to physical exertion. However, with regular reception of nitrates, addiction may develop (the anti-inanal effect can weaken and even disappear). To avoid this, nitrates are prescribed only intermittent with a time free of action at least 6-8 hours per day. Purpose of nitrates are different and depend on the functional class of angina. Thus, during angina, for example, I FC nitrates are prescribed only intermittent in the dosage forms of short action - sublingual tablets, nitroglycerin aerosols and isosorbide dinitrate. They should be used in 5-10 minutes to the intended physical activity that usually causes the attacks of angina. Under angina pharmacy II, the nitrates are also prescribed intermittently, before the intended physical exertion in the form of dosage forms of short or moderately prolonged action. With angina region III FC, 5-mononitrates of prolonged action with a neglected period of 5-6 hours are used. Under angina IV FC, when angina attacks may occur at night, nitrates should be prescribed so as to ensure their round-the-clock effect, as a rule, in combination with other antiagonal preparations.

Molotomine has a nitrate-like action. The drug reduces the tension of the vessel wall, improves collateral blood circulation in myocardium and has anti-aggregation properties. Available in 2 mg doses (comparable with isosorbide by dinitom 10 mg), 4 mg and retardorm 8 mg (duration of 12 hours). An important position is the indication for the appointment of nitrates and Molidomin - the presence of a confirmed myocardial ischemia.

Calcium antagonists (AK) along with pronounced anti-naigneal (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 chronic IBS with damage to the arteries of various other localization.

Antianginal effects have both subgroups of dihydropyridine (primarily nifedipine and amlodipine) and Nedigidropyridines (verapamil and diltiaze). The mechanism of action of these subgroups is different: peripheral vasodulation predominates in the properties of dihydropyridines, in the actions of NEDIGIDROPIRODINOV - negative chrono- and inotropic effects.

The undoubted advantages of AK is a wide range of their pharmacological effects aimed at eliminating the manifestations of coronary insufficiency - antiagonal, hypotensive, antiarrhythmic effects. This therapy has favorably and for atherosclerosis. Anti-theterosclerotic properties have already been demonstrated in relation to Amlodipine in the Prevent (5) study. In patients with different forms of CHD, verified with the help of quantitative coronary artwork, amlodipine significantly slowed down the progression of atherosclerosis in carotid arteries: according to the results of an ultrasound examination, the thickness of the carotid artery wall decreased by 0.0024 mm / year (p \u003d 0.013). After 3 years of treatment, the frequency of repeated hospitalization in connection with the deterioration of the state was less than 35%, the need for operations to revascularize myocardium - by 46%, the frequency of all clinical complications is 31%. The results of the study are extremely important, since the indicator "Intic / Media Sleepy Thickness" is an independent predictor for the development of myocardial infarction and brain stroke (6). In the MDPIT study, the appointment of diltiazem 2466 patients significantly reduced the risk of myocardial infarction, but did not affect total mortality (7). Studies have ended on the study of the effect of nifedipine extended action and amlodipine on the impaired endothelium-dependent vasodilation of the coronary arteries (Encore I and II and Camelot).

Nevertheless, today AK represent a very important class of drugs for the treatment of IBS. In accordance with the recommendations of the European Society of Cardiologists and the American College of Cardiologists, the AK are a mandatory component of anti-infan therapy of stable angina - both in the form of monotherapy (in the case of contraindications to β-adrenoblockers) and in the form of combined therapy in combination with β-adrenoblockers and nitrates. AK is especially shown in patients with vasospast angina and episodes of nonsense ischemia. AK in chronic IHD should be mainly appointed in the form of generation II drugs - forms of prolonged action, used 1 time per day. According to the data of the controlled studies, recommended during a stable angina dose of AK constitute for nefidapine 30-60 mg / day, verapamila 240-480 mg / day, amlodipine 5-10mg / day (8). It should be remembered that the purpose of Verapamil and Diltiazem is contraindicated in the presence of signs of heart failure, while amlodipine can be assigned under these circumstances without any consequences (9).

Other antiaginal drugs

These include, first of all, various preparations of metabolic action. Currently, the anti-ischemic and anti-infanal effectiveness of trimetazidine is proved. Indications for its use: IBS, prevention of angina attacks with long-term treatment. Trimetazidine can be assigned at any stage of angina stabilization therapy for increased antiagonal efficiency. But there are a number of clinical situations where trimethazidine can be a drug selection: in senior patients, in case of insufficiency of blood circulation of ischemic genesis, the syndrome of the weakness of the sinus node, with the intolerance of antiagonal hemodynamic effects, as well as during restrictions or contraindications to their intended purpose.

Recently, a new class of anti-inanal drugs was created - IF stream inhibitors in a sinus node. Their only representative of Ivabradin (Koraxan, Les Laboratories Servier) has a pronounced anti-infanal effect due to an exclusive decline in heart rate and elongation of the diastole phase, during which myocardial perfusion occurs (10). In the treatment of Coraxan, the total duration of the load test increases 3 times, even in patients already taking β-adrenoblays. (eleven). According to the results of the newly reported study, Beautiful Coraxan reliably reduces the risk of myocardial infarction at 36% (P \u003d 0.001) and the need to revascularization by 30% (P \u003d 0.016) in patients with IBS and CSS over 70 shots per minute (12). Currently, the spectrum of using this drug has expanded: this is chronic IBS as a preserved function of the left ventricle and with its dysfunction.

1. Short-range nitroglycerin to relieve angina and situational prophylaxis (patients should receive adequate instructions for the use of nitroglycerin) (B).
2. β1-adrenoblockers of prolonged action with dose titration to maximum therapeutic (a).
3. With poor tolerability or low efficiency of β-adrenoblocker monotherapy with calcium antagonists (a), prolonged nitrates (C).
4. With insufficient effectiveness of monotherapy β-adrenoblockers, the addition of calcium antagonists (B).

1. With poor portability of β-adrenoblockers, it is assigned an inhibitor of the IF channels of the sinus node - Ivabradin (B).
2. If monotherapy with calcium antagonists or combination therapy with calcium antagonists and β-adrenobloclockers ineffective, replacing calcium antagonist to prolonged nitrate (C).

1. Preparations of metabolic action (trimetazidine) as an addition to standard therapy or alternative to them with poor tolerability (B).

Note: The level of evidence from: the opinion of a number of experts and / or the results of small studies, retrospective analyzes.

Tactics of outpatient management of patients with stable IBS

During the first year of the disease, with a stable condition of the patient and good tolerance of drug treatment, the state of patients is recommended every 4-6 months, subsequently, with a stable course of the disease, it is enough to carry out an outpatient examination 1 time per year (according to the indications more often). With a thorough individual selection of doses of antichangal drugs, a substantial anti-inanal effect can be achieved by more than 90% of patients with stable angina phase II-III FC. To achieve a more complete antiagonal effect, combinations of different antiafactors are often used (β-adrenoblays and nitrates, β-adrenoblays and dihydropyridine AK, NEDIHIDROPIRODINIC AK and nitrates) (13). However, with the combined appointment of nitrates and dihydropyridine calcium antagonists, in 20-30% of patients, the antiagonal effect decreases (compared with the use of each drug separately), while the risk of side effects increases. It was also shown that the use of 3 anti-inanal drugs may be less efficient than treatment with drugs 2 classes. Before the appointment of the second drug should increase the dose of the first to the optimal level, and in front of the combined therapy with 3 drugs it is necessary to experience various combinations of 2 anti-infaneatives.

Special situations: syndrome x and vasospadic angina

Treatment of X. syndrome . Approximately half of the patients are effective nitrates, therefore, it is advisable to start therapy with this group of drugs. With the ineffectiveness of treatment, you can add ak and β-adrenobloclars. ACE and statins inhibitors reduce the severity of endothelial dysfunction and manifestation of ischemia during exercise, so they should be used in this group of patients. In complex treatment, metabolic therapy is also used. To achieve a persistent therapeutic effect in patients with syndrome X, an integrated approach with the use of antidepressants, aminoophylline (euphilline), psychotherapy, electrostimulation methods and physical workouts is necessary.

1. Treatment with nitrates, β-adrenoblockers and calcium antagonists in monotherapy or combinations (a)

2. Statins in patients with hyperlipidemia (B)

3. ACE inhibitors in patients with arterial hypertension (C)

1. Treatment in combination with other antiolated drugs, including metabolites (C)

1, aminoophyllin while maintaining pain, despite the execution of class I recommendations (C)

2. imipramine while maintaining pain, despite the execution of recommendations I class (C).

Treatment of vasospadic angina. The elimination of factors contributing to the development of vasospast angina, such as smoking, stress, is important. The basis of treatment is nitrates and ak. At the same time, nitrates are less effective in the prevention of attacks of rest angina. Calcium antagonists are more efficient to eliminate coronarrospasm. It is advisable to use nifedipine retard in a dose of 120 mg / day, verapamila to 480 mg / day, diltiazem to 360 mg / day. Combined therapy with prolonged nitrates and AK in most patients leads to the remission of vasospadic angina. Within 6-12 months after the cessation of angina attacks, it is possible to gradually reduce the doses of antiagonal drugs.

1. Treatment with calcium antagonists and by indications of nitrates in patients with normal angiograms or non-defensive damage to the coronary arteries (B).

Currently, the doctor's arsenal for the treatment of anginara is a complex of anti-ischemic, antithrombotic, hypolypidemic, cytoprotective and other drugs, which, with their differentiated purpose, much increases the effectiveness of treatment and improves the survival of patients with IHD.

1. PREVENTION OF CORONARY HEART DISEASE IN CLINICAL PRACTICE / RECOMMENDATIONS OF THE SECOND JOINT TASK FORCE OF EUROPEAN AND OTHER SOCIETIES ON CORONARY PREVENTION. / EUR. Heart J.-1998.-19.-1434-503.
2. Francis K. et.all. Clopidogrel Versus Aspirin and Prevent Recurrent Ulcer Bleeding. /N.Engl.j.med.-352.-238-44.
3. Treatment of stable angina Recommendations of the Special Commission of the European Society of Cardiologists. / Russian honey. Journal.-1998.-Tom 6, №1.-3-28.
4. Gurevich MA Chronic ischemic (coronary) heart disease. Manuals for doctors.-M. 2003. - 192c.
5. BUIHGTON R.P. Chec J. Furberg c.d. Pitt B. Effect of Amlodipine On Cardiovascular Events and Procedures. /J.am.coll.cardiol.-1999.-31 (SuppL.a) .- 314A.
6. O'LEARY D.H. Polak J.F. KRONMAL R.A. et al. Carotid-Arttery Intima And Media Thickness As a Risk Factor for Myocardial Infarction and Stroke in Older Adults. /N.Engl.j.Med.-1999.-340.-14-22.
7. The Multicenter Diltiazem PostInfarction Trial (MDPIT) Research Group. The Effect of DiltiaZem on Mortality and Reinfarction After Myocardial Infarction. /N.Engl.j.Med.-1988.-319.-385-92.
8. Olbinskaya L.I. Morozova i.e. Modern aspects of pharmacotherapy of coronary heart disease. / Attending physician.-2003.-№6.-14-19.
9. Packer M. O'connor C.M. Ghali J.K. et al. For the Prospective Randomized AmlodiPine Survival Evaluation Study Group. Effect of Amlodipine on Morbidity and Mortality in Severe Chronic Heart Failure. / New Engl.j.Med.-1996. -335.-1107-14.
10. Borer J.S. Fox K. Jaillon P. et al. Antianginal and Antiischemic Effects of Ivabradine, An If Inhibitor, in Stable Angina: A Randomized, Double-Blind, Multichentered, Placebo-Controlled Trial. /Circulation.-2003.-107.-817-23.
11. TARDIF J.C. et al. // ADSTRACT ESC.- MUNICH, 2008.
12. Fox K. et al. IVabradine and Cardiovascular Events in Stable Coronary Arttery Disease and Left Ventricular Systolic Dysfunction: A Rabdomised, Double-Blind, Placebo-Controlled Trial //lancet.-2008.-1-10.
13. Diagnosis and treatment of stable angina (recommendations). - Minsk, 2006.- 39 p.

IHD: treatment, prevention and forecast

The treatment of heart ischemia depends on the clinical manifestations of the disease. Tactics of treatment, reception of some drugs and selection of physical activity, each patient may vary greatly.

The course of treatment of heart ischemia includes the following complex:

• therapy without the use of drugs;
• therapy with the use of medicines;
• endovascular coronaohangioplasty;
• treatment with the use of surgery;
• other treatment methods.

Drug treatment of heart ischemia implies the adoption by a nitroglycerin patient, which is capable of stopping the seizures of angina, which is capable of the vasodilator effect in a short time.

This also includes the reception of a number of other medicines, which are appointed exclusively attending specialist. For their purpose, the doctor is based on data from the diagnosis of data from the diagnosis.

Preparations used in treatment

Theoapia for ischemic heart disease provides for the reception of the following drugs:

• Antiagreganta. These include acetylsalicylic acid and clopidogrel. Preparations, as it were, "dilute" blood, contributing to improving its fluidity and reducing the ability to adhere to platelets and erythrocytes to vessels. And also improve the passage of red blood cells.
• Beta adrenoblocrators. This is metoprolol. Carvedilol. Bisoprolol. Preparations that reduce the heart rate of myocardium, which leads to the desired result, that is, myocardium receives the required volume of oxygen. They have a number of contraindications: chronic pulmonary disease, pulmonary failure, bronchial asthma.
• Statins and fibers. These include Lovastatin. Fenofibat, Simvastatin. Rosavastatin. Atorvastatin). These drugs are designed to lower cholesterol in the blood. It should be noted that its level in the patients with the diagnosis of heap ischemia must be twice as lower than that of a healthy person. Therefore, drugs of this group are immediately used in the treatment of heart ischemia.
• Nitrate. This is nitroglycerin and isosorbide mononitrate. They are necessary to relieve the attack of angina. Possessing the vasodilatory impact on the vessels, these drugs make it possible in a short period of time to get a positive effect. Nitrates should not be used in hypotension - arterial pressure below 100/60. Their main side effects are headache and low blood pressure.
• Anticoagulants - Heparin, which, as it were, "dilutes" blood, which contributes to the relief of blood flow and stop the development of existing thrombus, and also does not give to develop new thrombam. The drug can be administered intravenously either under the skin in the stomach.
• Diuretics (thiazide - hypotheside, indapamide; looped - furosemid). These drugs are necessary to remove excess fluid from the body, thereby reducing the load on myocardium.

In the news (here) treatment of angina people by folk remedies!

Also use the following medical drugs: lysinopril. Captrapop, Enalaprin, antiarrhythmic (amiodar) drugs, antibacterial agents and other drugs (mexicor, ethylmethylhydroxypyridine, trimetazidine, mildronat, coronatar).

Restriction of exercise and diet

At physical exertion, the load on the heart muscle increases, as a result of which the need of myocardium of the heart in oxygen and the necessary substances is also increasing.

The need does not correspond to the possibility, therefore, the disease occurs. Therefore, an integral part of the treatment of IBS is the restriction of physical activity and gradually increasing it during rehabilitation.

Diet with heart ischemia also plays a big role. In order to reduce the load on the heart, the patient is limited in the reception of water and cook salt.

Also, much attention is paid to the restriction of those products that contribute to the progression of atherosclerosis. Fighting overweight, as with one of the main risk factors, is also an integral component.

It should be limited or refusing the following groups of products:

• animal fats (salary, butter, fatty meat varieties);
• fried and smoked food;
• products containing a large amount of salt (salted cabbage, fish, etc.).

It should be limited to the use of high-calorie food, especially fast absorbing carbohydrates. These include chocolate, cakes, candy, snob.

In order to adhere to normal weight, follow the energy and its amount that comes with the food used and the actual energy consumption in the body. At least 300 kilocalories should flow into the body daily. An ordinary person who is not engaged in physical work, spends about 2,000 kilocalories per day.

Surgery

In special cases, surgical intervention is the only chance to save the life of a sick person. The so-called coronary shunting is an operation at which the coronary vessels are combined with external. Moreover, the connection is performed in the place where the vessels are not damaged. Such an operation significantly improves the nutrition of the heart muscle with blood.

The shunting of the Aorticorona is an operational intervention, in which the aorta is bonded with the coronary artery.

Balloon dilatation of vessels - an operation at which cylinders with a special substance are introduced into the coronary vessels. Such a balloon expands to the required damaged vessel. Enter it to a coronary vessel through another major artery using the manipulator.

Method of endovascular coronaugulagioplasty is another way of treating heart ischemia. Balloon angioplasty and stenting applied. Such an operation is carried out under local anesthesia, the auxiliary tools are introduced more often to the artery of the femoral, piercing the skin.

The operation controls the X-ray apparatus. This is an excellent alternative to a direct surgical operation, especially in the case when the patient has certain contraindications to it.

In the treatment of heap ischemia, other methods that do not provide for the use of drugs can be used. These are quantum therapy, treatment with stem cells, hirudotherapy, methods of shock-wave therapy, the method of enhanced outdoor counterpulsion.

Interesting facts about the disease in the news - the history of ischemic heart disease. The very essence of the disease and its classification is revealed.

Treatment at home

How can I get rid of the ischemia of the heart and carry out its prevention at home? There are a number of ways that will require only patient's patient desire. These methods predetermine the activities that are aimed at improving the quality of life, that is, the minimum of negative factors.

Such treatment implies:

• refusal of smoking, including passive;
• refusal of alcohol;
• diet and rational nutrition, which includes products of plant origin, low-fat meat, seafood and fish;
• mandatory use of food rich in magnesium and potassium;
• refusal of oily, fried, smoked marinated and too salted food;
• consumption of low cholesterol food;
• normalization of physical exertion (required outdoor walks, swimming, jogging; exercise on the exercise bike);
• gradual hardening of the body, including wiping and dumping cool water;
• a sufficient night's sleep.

The degree and type of load should define a specialist doctor. Also need control and constant advice with the attending physician. It all depends on the phase of the aggravation and degree of the disease.

Non-drug treatment includes measures to normalize blood pressure and treatment of existing chronic diseases, if any.

Prevention

As preventive measures to prevent the occurrence of heart ischemia, the following should be selected:

• it is impossible to overload yourself to work and often rest;
• get rid of nicotine addiction;
• do not abuse alcohol;
• eliminate the use of animal fats;
• food with a high calorie content limit;
• 2500 kilocalories per day - limit;
• food should be high protein products: cottage cheese, fish, low-fat meat, vegetables and fruits;
• moderately physical education, arrange hiking.

What is the forecast?

The forecast is mostly unfavorable. The disease is steadily progressing and is chronic. Treatment only only suspends the process of the disease and slows down its development.

Timely consultation of the doctor and proper treatment improve the forecast. A healthy lifestyle and full nutrition also helps to strengthen the heart function and improving the quality of life.

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Has a pronounced antiagonal effect;

Increases tolerance to physical exertion;

Has a cardioprotective action;

Improves the erectile function in patients with IHD.

Chronic Ischemic Heart Disease: Treatment News

Published in the journal:
"Consilium Medicum" No. 1, 2016 volume 18

Yu.A. Karkov
FSBI Russian Cardiological Scientific and Production Complex of the Ministry of Health of Russia. 121552, Russia, Moscow, ul. 3rd Cherepkovskaya, 15a

The main goal of the treatment of chronic ischemic heart disease (IBS) is to reduce the risk of developing complications, primarily myocardial infarction, and mortality (increase in life expectancy) when ensuring good quality of life. Recently, new opportunities have appeared in the treatment of IBS: an increase in the duration of the use of double antiagregative therapy and a more intensive decrease in the level of cholesterol of low-density lipoproteins using combined therapy, new antianginal therapy schemes and some others. The positions of invasive treatment are refined, including the ratio between endovascular treatment and coronary shunting. The modern multicomponent strategy of the patient with chronic IBS allows you to achieve not only improvement in the quality of life, but also an increase in life expectancy, including without cardiovascular complications.
Keywords: chronic ischemic heart disease, medication treatment, anti-infanal therapy, invasive treatment.

Chronic ISChemical Heart Disease: Treatment News

Yu.A.Karpovh.
RUSSIAN CARDIOLOGICAL SCIENTFIC-INDUSTRIAL COMPLEX OF THE MINISTRY OF HEALTH OF THE RUSSIAN FEDERATION. 121552, Russian Federation, Moscow, 3-Ia Cherepkovskaia, d. 15A

The Main Aim of Chronic Ischemic Heart Disease (IHD) Treatment Is to Reduce The Risk of Complications - Especially A Myocardial Infarction, And Mortality (To Increase Life Excectancy) in Providing A Good Quality Of Life. New Treatment Options for IHD Have Been Worked Out Recently: Therase of Duration Of Dual Antiplatelet Therapy and Intensive Lowering Of Low-Density Lipoprotein Cholesterol Levels As A Part of Combined Therapy, New Schemes of Antianginal Therapy and Some Others. The Characteristics of Invasive Treatment, Including The Correlation Between Endovascular Treatment and Coronary Arttery Bypass Graft Surgery, Have Been Outlined. Modern Multi-Component Strategy Using For Management of Patients WITH CHRONIC IHD ALLOWS US TO IMPROVE NOT ONLY THE QUALITY OF LIFE, BUT ALSO TO INCREASE LIFE EXPECTANCY, WITHOUT CARDIOVASCULAR COMPLICATIONS.
Key Words.: Chronic Ischemic Heart Disease, Drug Therapy, Antianginal Therapy, Invasive Treatment. [Email Protected]

About 1/2 of all fatal outcomes during the year in our country accounted for cardiovascular diseases, mainly ischemic heart disease (IBS). In this regard, the solution of the most important social task is to increase the life expectancy until 75.3 years by 2030 - cannot be implemented without increasing the effectiveness of the treatment of patients with IHD. It should be recalled that the main goal of the treatment of chronic IBS is to reduce the risk of developing complications, primarily myocardial infarction (im) and mortality (increasing life expectancy) when ensuring good quality of life (CZh). In our country, according to the latest data, there are more than 8 million patients with an established diagnosis of CHA, which should receive modern drugs, and, if necessary, in certain clinical situations, and invasive treatment, are located on outpatient observation.

The scheme of drug therapy in accordance with the recommendations on the maintenance of patients with a stable IHD included drugs with a proven positive impact on the forecast for the disease (Table 1), which are required for appointment if there are no direct contraindications to their reception, as well as a numerous antiagonal group or Anti-Hiscetic drugs.

The prevention of the complications of the IBS is carried out by appointing antiagregants (acetylsalicylic acid - ASK or clopidogrel), statins (it is important to achieve the target level of cholesterol of low-density lipoproteins - xs LDL), drugs blocking the activity of the renin angiotensin system. There is evidence of the effectiveness of inhibitors of angiotensin gluttering enzyme (IAPF) perindopril and ramipril, and in their intolerance - angiotensin receptor blockers. The most priteled effects of the IAPF in patients with a low fraction of emission of the left ventricle (FV LV), transferred to them, diabetes mellitus (SD), arterial hypertension (AG), however, in patients with IHS without specified states, you can count on a reduction in cardiovascular risk . Also in the treatment regimen of the IBS were ß-adrenoblays (ß-LB), which were recommended for all patients after those transferred to them.

What changes have occurred or additional possibilities have appeared, the use of which in everyday clinical practice improves the results of the treatment of patients with IBS?

Preparations that improve the forecast for chronic IBS

Antiagregant therapy. Most patients with a stable IBC continue to be preferred to the assignment of ASK in the dose range from 75 to 150 mg / day, which is associated with a favorable benefit ratio, as well as the low cost of treatment. Clopidogrel is considered as a drug of the 2nd line appointed at a dose of 75 mg 1 time per day with the intolerance of ASK or as an alternative to ACC in patients with a common atherosclerotic lesion.

Combined or double antitrombocutic therapy (dates), including ASK and a second anti-aggregant (ticugrellor or clopidogrel), is a standard for patients who survived acute coronary syndrome -ox (depending on the strategy of maintenance), as well as patients with stable IBS subjected to planned percutaneous Coronary interventions - Chkv (ASK with clopidogrel). The duration of treatment in these cases, depending on the type of the implanted stent, did not exceed 1 year after the event. Recently, the efficacy and safety of dates in patients after 1 year and more transferred to them were actively studied. After completing several studies, especially the studies of Pegasus-Timi 54, it became obvious that in patients after those transferred after 1 year it is possible to consider the possibility of longer dates, especially in cases of high risk of ischemic complications and low risk of bleeding, which was noted in new European Recommendations for the treatment of patients with it without lifting ST. Recently, a new indication was registered for the use of a ticagrelor.

As for patients with chronic IBS, according to American recommendations for the maintenance of these patients, dates can be considered in cases where there is a high probability of developing ischemic complications.

Lipid lining therapy. All patients with proven IBS recommended the appointment of statins in doses that allow you to achieve the target level of HC LDL<1,8 ммоль/л или более 50% от исходного уровня. Для этих целей часто используются высокие дозы статинов - аторвастатин 40-80 мг или розувастатин 20-40 мг. Вместе с тем недавно в исследовании IMPROVE-IT было показано, что у пациентов с ОКС длительное применение комбинированной терапии симвастатин + эзетимиб, которая больше снижает ХС ЛПНП, чем монотерапия, достоверно улучшает сердечно-сосудистый прогноз . Это позволяет рекомендовать такую комбинированную терапию у больных с недостаточным снижением ХС ЛПНП на монотерапии статинами.

Recently registered (USA and the European Union) A new class of lipid lining drugs - PCSK9 monoclonal antibodies or a propreteen convertise of subtilisine-cake-type 9 (PSCT9) at subcutaneous administration 1 time in 2-4 weeks reduce HC LDL by 40-60%, including including on the background of statins, possess good tolerability. Already, these drugs (the registration of drugs alirocumab and evocumab in Russia is planned in 2016) can significantly increase the effectiveness of patient therapy with the family form of hypercholesterolemia, as well as in the intolerance of statins. In the future, with a favorable completion of a series of clinical studies, in which the effectiveness and safety of PCT9 inhibitors during prolonged use are studied, these drugs can be used in the treatment of patients with IHDs together with statins to overcome the "residual" risk.

ß-ab.. As already noted, ß-AB was recommended to all patients after it without limitation on the duration of use, regardless of the presence of angina and other testimony to their application, since evidence of improving the forecast in this cohort of patients was previously obtained. However, many experts noted that the appointment of ß-AB after 3 years and more after the patients suffered without angina and without heart failure does not have evidence of improving the forecast. The fact is that studies with a duration of more than 2-3 years in order to assess the influence of ß-AB to the forecast after it was not. Recently, in American recommendations for the diagnosis and treatment of a stable IHD, it was first noted that if after 3 years after it does not have angina, chronic heart failure with a reduced FV LV, AG, then the therapy of ß-ab can be finished. Thus, it is indicated for the option of the therapy of ß-ab in the absence of angina and other indications for the purpose of the preparations of this class.

Antianginal (Anti-Hishemic) Therapy

Therapy aimed at eliminating the ischemic manifestations of angina and / or nonsense myocardial ischemia includes ß-AB, calcium channel blockers (BKK), prolonged nitrates, inhibitor of the IF cells of the sinus node cells (Ivabradin), cytoprotective preparations (trimetazidine), late sodium inhibitor Current (ranolazine) and activator of potassium channels (nicorandyl). All these drugs have an antiagonal (anti-hiece) effect, which has been proven in the course of controlled clinical studies.

ß-ab.. For the treatment of angina ß-k, they are prescribed in a minimum dose, which, if necessary, gradually increases to complete control of angina attacks or maximum dose. It is believed that the maximum decrease in the need of myocardium in oxygen and the growth of coronary blood flow is achieved with the frequency of heart rate (CSS) 50-60 UD / min. In case of insufficient effectiveness, as well as the impossibility of using the maximum doses of ß-AB due to unwanted manifestations, it is advisable to combine them with calcium antagonists - AK (dihydropyridine derivatives of long-term action) or Ivabradin. If unwanted phenomena occurs, it may be necessary to reduce the dose of ß-ab or even cancel them. In these cases, it should be considered the appointment of other rhythm-rejuvenating drugs - verapamila or Ivabradin. The latter, unlike verapamil, can join ß-ab for improving the control of heart rate and increase anti-isice efficiency. If necessary, you can join ß-ab Nicoradil. In patients with stable angina, ranolazine or trimetazidine can be used in combination with SD.

Table 1. Medical treatment of chronic IBS


BKK. Preparations of this group are used to prevent the attacks of angina. The rhythmous BKK (Diltiazem, Verapamil) reduces heart rate, inhibit myocardial reductions and can slow down atrioventricular conductivity. AK is also prescribed in cases where ß-ab is contraindicated or not transferred. These drugs have a number of advantages over other antiagonal and anti-hichokes and can be used in a wider range of patients with related diseases than ß-ab. Preparations of this class are shown when a combination of stable angina with AG. It is recommended to improve the control of the angina to use a combination of dihydropyridine ak with ß-ab.

Nitrates and nitrate-like. The variety of dosage forms allows the use of nitrates to patients with a different severity of the disease both to relieve and the prevention of angina attacks. Nitrates can be used in combination with other antichangal drugs. The weakening of sensitivity to nitrates is often developing with long-term use of prolonged action drugs or transdermal dosage forms. For prevention of tolerance to nitrates and its elimination, intermittent reception of nitrates is recommended during the day; Reception of nitrates of average duration of action - 2 times a day, prolonged action is -1 times a day; Alternative Molidomin therapy.

Molotomine, who is close to nitrates on the mechanism of anti-naiginal action, are prescribed with nitrate intolerance. It is usually prescribed to patients with contraindications to the use of nitrates (with glaucoma), with poor tolerability (severe headache) of nitrates or tolerance to them.

Inhibitor of the sinus knot Ivabradin. At the heart of the antichangal action of Ivabradin is a selective decrease in the heart rate by inhibiting the transmembrane ion ion current if in the sinus node cells. In contrast to ß-AB, Ivabradin reduces only the heart rate, does not affect the reduction, conductivity and automaticism of myocardium, as well as blood pressure (AD). The drug is recommended for the treatment of angina in patients with sinus rhythm with contraindications / intolerance to the reception of ß-ab or together with ß-AB in their insufficient antiagonal effect. It was shown that the accession of the drug to ß-AB in patients with IBS with a decreased FV LV and CSS\u003e 70 UD / min improves the disease forecast. The drug is not recommended to be appointed simultaneously with the BCC.

Nicorandil. Antianginal and anti-hichokes drug Nicoradil simultaneously has the properties of organic nitrates and activates adenosine trifhosphate-dependent potassium channels. Reception of nicorandila effectively reduces myocardial ischemia - provides a simultaneous decrease in after- and preloading to LV with a minimal effect on hemodynamics and does not have many shortcomings characteristic of standard opponents. Opening adenosintrifosphate-dependent potassium channels of mitochondria, Nicorandil completely reproduces the protective effect of ischemic preconditioning: contributes to energy saving in the heart muscle and prevents irreversible cellular changes in the conditions of ischemia and reperfusion.

It is shown that a single dose of nicorandila (10 or 20 mg), adopted 2 hours to intradermal coronary intervention in patients with OKS, reduced the frequency of cases of increasing the level of troponin I, as well as the frequency of increase in troponin 3 and 5 times compared to the upper boundary of the norm Compared to the control group. It is also proved that nicorandyl is able to reduce the rate of development of arrhythmias, aggregation of platelets, stabilize the coronary plaque, contribute to a decrease in the severity of co-coordard oxidation, normalize the function of the endothelium and the sympathetic nervous activity in the heart.

Nicorandil does not cause tolerance development, does not affect hell, heart rate, conductivity and myocardial reductions, lipid metabolism and glucose metabolism. It is recommended for the treatment of patients with microwave walls (with ineffective ß-ab and ak). The drug can also be used to relieve angina attacks.

There are no data on the impact on the prognosis in patients with a stable IHD for other anti-native drugs. The exception was the drug Nicorandil, which in a randomized double-blind placebo-controlled study of the UK (Impact of Nicorandil In A ^ Ta; United Kingdom, N \u003d 5126, the average surveillance period of 1.6 years) significantly reduced the risk of death from IHS, nefato it and unscheduled hospitalization of communication with heartache (p \u003d 0.014) and 21% reduced the risk of ox (p \u003d 0.028). Moreover, the maximum decrease in the absolute risk of unwanted events was observed in patients with the greatest source risk.

In a multicenter prospective observation study in the JCAD parallel groups (Japanese Coronary AG: YSU Disease; Japan, N \u003d 5116, the average surveillance period of 2.7 years) studied the influence of nicoordil for remote outcomes in patients with IHD. The frequency of the main endpoint (death from any reason) in the Nicorandila group was 35% lower compared to the control group (p \u003d 0.0008). Also, in the Nicorandila group, a significant decrease in the frequency of additional end points was noted: cardiac death (-56%), the fatal of them (-56%), cerebrovascular and vascular death (-71%), stagnant heart failure (-33%), over-hearth blood circulation stop And breathing (-64%).

In another observation study of the OSAKA ACUTE CORONARY INSUFFICIENCY STUDY; Japan, N \u003d 1846, the median of the surveillance period of 709 days) patients with acute them, who suffered an emergency Chkv, Nicorandil, appointed orally from the moment of extracting, reduced the risk of death from any reasons for 50, 5% (p \u003d 0.0393), regardless of the outcome of the CHV. However, Nicorandil is used in clinical practice only for angina therapy.

Randomized clinical studies with the use of nicorandila domestic production revealed additional clinical effects in patients with stable IBS in relation to isosorbide-5-mono-nitrate: improving the indicators of the erectile function and an increase in the increment of the diameter of the cavernous arteries in men, an increase in the velocity of cerebral blood flow, which is especially important for Elderly patients who have insufficient cerebral circulation. Adding nicorandila to standard therapy of stable angina facilitated a significant reduction in the concentration of highly sensitive C-reactive protein (P \u003d 0.003) and the level of fibrinogen (P \u003d 0.042) against the background of rosuvastatin intake, which confirms the positive effect of nicoradila on the processes of reduction of oxidative damage and systemic inflammation. The use of nicoradil in patients with a stable angina of the functional class III, complicated by heart failure with a low FV LV, has not only allowed to obtain a more pronounced antiagonal effect, but also improve the systolic function of the heart, reduce the remodeling of the LV.

Ranolazin Selectively inhibits late sodium channels, which prevent an overload of intracellular calcium - a negative factor in myocardial ischemia. Roland is reduced by the redundancy and stiffness of myocardium, improves myocardial perfusion, reduces the need of myocardium in oxygen, while not affects the heart rate and blood pressure. It is usually prescribed in combination therapy with insufficient anti-angular effectiveness of basic drugs.

The recently completed study studied the influence of ranolazine over the course of IHD in patients after incomplete revascularization of myocardium using PCV with stenting. It has previously been shown that in 80% of patients after CVD there is incomplete reflailing of myocardium, which is subsequently associated with higher mortality and repeated hospitalization with revascularization. River-PCI study included 2619 patients between November 2011 and May 2013 in 245 centers in Israel, USA, Europe and Russia, which were randomized to obtain a ranpolazine of 1000 mg 2 times a day (N \u003d 1332) or placebo (n \u003d 1297). Three-sized lesions were in 44% of patients, 33% had chronic complete occlusion and 14% had previously transferred the operation of the Aorticoronary shunting (AKSH). All had incomplete revascularization, which was determined as the presence of one or more lesions with a 50% diameter of stenosis and more in the coronary artery (ka) 2 mm in diameter and more.

The average observation period was 643 days, during which 26.2% of the Panolazine Group and in 28.3% of the placebo group have events of the combined primary endpoint (associated myocardial ischemia revascularization or hospitalization without revascularization). The difference did not have a reliable value (risk ratio of 0.95). At the same time, the researchers noted a very high frequency of cardiovascular events in patients with incomplete revascularization. Almost 1/2 of cases of recycled revascularization associated with the development of ischemia, the CCV was performed on stenosis, which were previously left untreated. There was no reliable differences in the frequency of development of individual events of primary or secondary end points: revascularization associated with ischemia (15.3% against 15.5%, respectively, in Ranolazine and placebo groups); hospitalization associated with ischemia without revascularization (15.3% against 17.9%); Cardiovascular death (1.6% against 1.6%); Sudden heart death (0.5% against 0.9%) or im (8.4% against 9.0%). In the Rolanzin group, transient ischemic attacks were more common compared to the placebo group (1.0% against 0.2%; risk ratio 4.36; p \u003d 0.02) and reliably more patients finished research prematurely for all reasons (40.0 % against 35.7%, p \u003d 0.006); Table. 2.

One of the possible reasons for the unsuccessful completion of the project, researchers consider the lack of objective evidence of the resumption of ischemia after the CCV as a criterion for inclusion in the study. Thus, the use of ranolazine in patients with chronic IBS after incomplete revascularization does not affect the disease forecast.

Table 2. Research River-PCI: Effect of Ranolazine on the course of IHD in patients with incomplete revascularization after PCV

Events	Rolandzine (n \u003d 1332)	Placebo (n \u003d 1297)	R
Primary endpoint *	345 (26,2%)	364 (28,3%)	ND
Revascularization associated with ischemia	15,3%	15,5%	ND
Hospitalization associated with ischemia without revascularization	15,3%	17,9%	ND
THEM	8,4%	9,0%	ND
Death from cardiovascular causes	0,5%	0,9%	ND
Tradality ischemic attack	1,0%	0,2%	0,02
Stopped receiving	189 (14%)	137 (11%)	0,04

* Primary endpoint - revascularization associated with ischemia + hospitalization associated with ischemia without revascularization.
Patients with IBS (n \u003d 2619) subjected to CWV with incomplete revascularization of more than 1 artery with a diameter of more than 2 mm with stenosis
more than 50% were divided into 1000 mg ranolazine groups 2 times a day and placebo; ND - unreliable.


After publication of the main result of the River-PCI study, a new analysis of the assessment of QG on Quality of Quality of Life was conducted. Analysis of 2389 participants in the study showed that although in both groups there was a significant improvement in the KZ on the scale of the Seatlovsky questionnaire for 1 month and 1 year after the index PCV, reliable differences between the Ranolazin and Placebo groups were not detected. However, in patients with diabetes and in a group with more severe angina, it was originally a reliable improvement in this questionnaire after 6 months after the intervention, which was leveled by 12 months.

Trimetazidin. The drug is an anti-host metabolic modulator, improves myocardial metabolism and energy supply, reduces myocardium hypoxia, without influencing hemodynamic performance. It can be appointed with any other antichangal drugs. Recently, restrictions were made to prescribe the drug with motor disorders (Parkinson's disease, essential tremor, muscle rigidity and restless legs). Currently, the effectiveness of the drug is being studied in reducing the risk of cardiovascular events in more than 7 thousand patients after CWV with stenting in an international randomized placebo-controlled study (AT-PCI).

Features of medication treatment of vasospadic angina

ß-AB with vazospad angina against the background of angio-graphically intact ka is not recommended. The best results for the prevention of ischemia in patients with vasospadic angina, show BKK. At the same time, there are practically no data on the effect of such therapy on the forecast of vasospadic angina. Recently, researchers from the Japanese Coronary Spasm Association conducted a multicenter study, in which 1429 patients were included (the average age of 66 years; men / women 1090/339) with vasospast angina (the diagnosis was exhibited by solving the participating doctors). More than 90% of patients received BKK therapy; 695 (49%) took different nitrates, such as nitroglycerin, isosorbide mononitrate and dinitrate (551 patients) and nicorandyl (306 patients). The primary end point was the sum of cardiac events (cardiovascular death, nefatal, hospitalization with unstable angina or heart failure, successful resuscitation).

During the study (on average, 32 months), the events of the primary endpoint were noted in 5.9% of patients. According to the analysis of the same selected steam, the total frequency of cardiac events was the same in patients who received and did not receive long-term therapy with nitrates (11% against 8%, respectively for 5 years; risk ratio 1.28; 95% confidence interval - di 0.72 -2.28). Monotherapy Nicoradil was associated with a neutral influence on the forecast for a vasospast angina (risk ratio of 0.8; 95% di 0.28-2.27). However, according to multifactorial analysis (COX model), the simultaneous use of different nitrates together with nicorandyl may increase the risk of cardiac events (risk ratio of 2.14; 95% di 1.02-4.47; p \u003d 0.044), especially when Simultaneous use of nitroglycerin and nicorandila. It was concluded that the long-term use of nitrates in combination with BKK did not improve the prognosis in patients with vasospadic angina patients.

In cases where the spasm of ka takes place on the background of stenzing atherosclerosis, small doses of ß-ab - in combination with dihydropyridine ak can be prescribed. The prognostic effect of ASK, statins, IAPF with vasospadic angina against the background of angiographically intact ka is not studied.

Features of medication treatment of microvascular angina

Currently, the assignment of statins and antiagregants is also recommended for the treatment of this form of the IBC. To prevent attacks, ß-ab is prescribed, and in case of insufficient efficiency, AK and long-acting nitrates are used. In cases of persisting angina, IAPF and Nicoradil are prescribed. Previously, clinical observations on the effectiveness of nicoradil in patients with this shape of angina were published.

In the ending recently, the study of RWISE was attended by 142 patients (96% of women; average age 55 years old) with microvascular angina. In addition to symptoms associated with myocardial ischemia, all had no obstructive lesion of ka (stenosis less than 50%) and a reduced coronary reserve (less than 2 5) in a sample with acetylcholine. In this placebo-controlled study, the ranolazine was not effective in reducing the number of seizures of the stainlessness of the stress or the improvement of myocardial perfusion (p \u003d 0.81). However, in the Rolazine group, there was a decrease in the symptoms of depression (p \u003d 0.009). Thus, in patients with microvascular angina, the effect of the drug on the reserve index of myocardial perfusion was not revealed.

Myocardial revascularization with chronic IBS

When discussing the issue of the revascularization of myocardium during stable angina (balloon angioplasty with stenting, ka or AKSH), the following circumstances are taken into account:

1. The effectiveness of antianginal therapy. If, after prescribing the patient, including combined therapy in optimal doses, it remains the attacks of angina with an unacceptable for a particular patient with a frequency, it is necessary to consider revascularization.
2. The results of load samples. The results of any load sample can identify the high-risk criteria of complications that are talking about an unfavorable remote forecast.
3. Risk of intervention. The anatomical features of the destruction of ka, the clinical characteristics of the patient, the operational experience of this institution are taken into account. As a rule, the invasive procedure refrain in cases where the intended risk of death during its implementation exceeds the risk of death of a particular patient within 1 year.
4. The question of conducting invasive treatment should be discussed in detail with the patient, and the decision is to be taken collegially with the participation of the attending physician, surgeon and invasive cardiologist. After successful invasive therapy, it is necessary to continue to make drugs.

The choice of myocardial revascularization method

It should be recalled that the previously conducted studies, in particular the study, did not establish advantages in improving a remote forecast when comparing two strategies for patients with a stable IHD - only optimal drug therapy (OMT) or PCV with implantation mainly metal uncoated stents + OMT. Recently, the results of almost 12-year observation of patients who previously participated in the Courage study were published. It turned out that with longer periods of observation, the number of dead from all reasons in both groups was not statistically different (Table 3).

These and other evidence suggests that CCV is shown, as a rule, only in the case of ineffective anti-infanal treatment in order to improve the CZ patients with a stable IBS, since this method of invasive therapy does not affect the risk of developing cardiovascular events and mortal outcome.

Table 3. Courage study: the effect of PCV for remote survival in patients with stable IBS

Information on survival was available for 1211 patients or 53% of the original population
with an average observation period of 11.9 years. In total, 561 patients died during observation, of which
180 - during the first study and 381 - during the extended period of observation

Successful shunting improves not only KZ, but also in a number of clinical situations - the prognosis of the disease, reducing the risk of developing nefatal and death from cardiovascular complications. This refers to patients who have stenosis more than 50% of the main trunk of the left ka; Scrogulation of the proximal segments of all three basic ka; coronary atherosclerosis of other localization with the involvement of the proximal department of anterior downward and envelope of the arteries; multiple occlusion ka; Diffuse distal hemodynamically significant stenosis. Reducing the systolic function of LV (FV Lzh<45%) является дополнительным фактором в пользу выбора шунтирования как способа реваскуляризации миокарда.

In recent years, several randomized studies have been conducted, in which the results of CSH and CCV in patients with a multi-sued lesion of ka were compared. In the studies of Syntax, Freedom and Artsii, only stents covered with medicine I generation were used. The frequency of stencil thrombosis was from 5 to 10% for 5 years. Since the stanta thrombosis is accompanied, as a rule, an unfavorable outcome, it determined the worst forecast in a group of pentated patients compared with the operated. When using the henth of the generation of the II generation, the frequency of development of wall thrombosis and, it is important to emphasize, the need for repeated revascularization is less. In a recent metaanalysis, which carried out a comparison of stenting and CS in the treatment of patients with a multi-sized lesion patient, it was shown that the frequency of repeated revascularization is constantly reduced by changing the CCV technology from the greatest when the cylinders are smaller when the hentings with the generation I generation and the minimum The case of the implantation of the henth of the heating of the II generation. Two major studies (Excel and Noble) are currently being conducted, in which the effectiveness of the treatment of patients with an unprotected lesion of the main trunk of the left and complex lesion with a low or intermediate SYNTAX index using a new generation of medicinal coating stents against KSH is being studied. The first results of these studies are expected in 2016.

Conclusion

IHD refers to frequently encountered cardiovascular diseases and is the main cause of cardiovascular mortality in Russia. The treatment regimen with the purpose of antiagregants, statins, blockers of the renin-angiotensin-aldosterone system and anti-infanal drugs should be used in all patients with a diagnosis of stable IHS flowing with the attacks of angina.

With the occurrences of angina, despite the treatment and under certain clinical situations, invasive treatment is carried out, the doctor, a coronary surgeon and an invasive cardiologist take part in the choice of the patient's opinion.

The modern multicomponent strategy of the patient with chronic IBS makes it possible to achieve not only the improvement of the KZH, but also an increase in life expectancy, including without cardiovascular complications.

Literature

1. 2013 ESC Guidelines on the Management of Stable Coronary Artery Disease. The Task Force On The Management of Stable Coronary Arttery Disease of the European Society of Cardiology. EUR HEART J 2013; 34: 2949-3003.
2. Rational pharmacotherapy of cardiovascular diseases. Ed. E.I. Schazov, Yu.Akarpova. M.: Litterra, 2014; c. 28-36. / Ratsional "Naia Farmakote-Rapiia Serdechno-Sosudistykh Zabolevanii. Pod Red. E.I.Chazova, IU.A.Karpova. M.: Lit-Terra, 2014; c. 28-36.
3. Bonaca MP, Bhatt DL, COHEN M ET AL.PEGASUSTIMI 54 STEERING COMMITTEE AND INVESTIGATORS. Long-Term Use of Ticagrelor in Patients with Prior Myocardial Infarction. N ENGL MED 2015; 372: 1791-800.
4. Mauri L, Kereiakes K, Jeh RW et al. The Dapt Investigators. Twelve or 30 Monhs of Dual Antiplatelet Terapy After Drugeluting Stems. N ENGL J MED 2014; 371: 1016-27.
5. FIHN SD, Blankenship JC, Alexander KP et al. 2014 ACC / AHA / AATS / PCNA / SCAI / STS Focused Update of the Guideline for the Diagnosis and Management of Patients with Stable Ischemic Heart Disease. Circulation 2014; 130: 1749-67.
6. Cannon CP, Blazing Ma, Giugliano RP et al. Improve-IT Investigators. Ezetimibe Added to Statin Therapy After Acute Coronary Syndromes. N ENGL J MED 2015; 372: 2387-97.
7. Kinoshita M, Sakai K. Pharmacology and Therapeutic Effects of Nicorandil. Cardio-VASC Drugs Ther 1990; 4: 1075-88.
8. MEANY TB, Richardson P, Camm AJ et al. Exercise Capacity After Single and Twice-Daily Doses of Nicorandil in Chronic Stable Angina Pectoris. Am j Cardiol 1989; 63: 66-70.
9. Yang j, zhang j, cui w et al. Cardioprotective Effects of Single Oral Dose of Nicorandil Before Selective Percutaneous Coronary Intervention. Anadolu Kardiyol Derg 2015; 15 (2): 125-31.
10. Airaksinen Ke, Huikuri HV. Antiarrhythmic Effect of Repeated Coronary Occlusion During Balloon Angioplasty. J am Coll Cardiol 1997; 29 (5): 1035.
11. Sakamoto T, Kaikita K, Miyamoto S et al. Effects of Nicorandil On Endogenous Fibrinolytic Capacity In Patients with Coronary Artery Disease. CIRC J 2004; 68: 232-56.
12. IZUMIYA Y, KOJIMA S, ARAKI S ET AL. Long-Term Use Of Oral Nicorandil Stabilizes Coronary Plaque in Patients with Stable Angina Pectoris. Atherosclerosis 2011; 214 (2): 415-21.
13. Markham A, Plosker GL, GOA KL. Nicorandil.. An Updated Review Of Its Use in Ischaemic Heart Disease with Emphasis on Its Cardio-Protective Effects. Drugs 2000; 60: 955-74.
14. SEKIYA M, SATO M, FUNADA J ET AL. Effects of the Long-Term Administration of Nicorandil On Vascular Endothelial Function and The Progression of Artteriosclerosis. J Cardiovasc Pharmacol 2005; 46 (1): 63-7.
15. Kasama S, Toyama T, Sumino H et al. Long-Term Nicorandil Therapy Imprives Cardiac Sympathetic Nerve Activity After Reperfusion Therapy In Patients with First Acute Myocardial Infarction. J Nucl Med 2007; 48 (10): 1676-82.
16. Kasama S, Toyama T, Hatori T et al. Comparative Effects of Nicorandil with Isosorbide Mononitrate on Cardiac Sympathetic Nerve Activity and Left Ventricular Function in Patients with Ischemic Cardiomyopathy. Am Heart J 2005; 150 (3): 477.e1-477.e8.
17. THE IONA STUDY GROUP. Effect of Nicorandil on Coronary Events in Patients with Stable Angina: The Impact of Nicorandil In Angina (Iona) Randomised Trial. Lancet 2002; 359: 1269-75.
18. THE IONA STUDY GROUP. Impact of Nicorandil in Angina: Subgroup Analyses. Heart 2004; 90: 1427-30.
19. Horinaka S, Yabe A, Yagi H et al. Effects of Nicorandil On Cardiovascular Events in Patients with Coronary Arttery Disease In The Japanese Coronary Arttery Disease (JCAD) Study. CIRC J 2010; 74 (3): 503-9.
20. Sakata Y, Nakatani D, Shimizu M et al. Oral Treatment with Nicorandil At Discharge Is Associated with Reduced Mortality After Acute Myocardial Infarction. J Cardiol 2012; 59 (1): 14-21.
21. Bulakhova E.Yu., Korennova O.Yu., Kondrasheva M.N. and etc. The clinical advantages of Nicorandyl therapy compared to isosorbide-5-mononitate in patients with IHD. A heart. 2013; 12, №2 (70): 83-7. / Bulakhova E.Iu., Korennova O.IU., Kondrasheva M.N. I DR. Klinicheskie Preimushchestva Terapii Nikorandilom Po Sravneniiu S Izosorbid-5-Mononitratom U Bol "Nykh Ibs. Serdtse. 2013; 12, №2 (70): 83-7.
22. RESERVANOVA Yua, Adamchik A.S. Evaluation of the anti-hype and cardioprotective efficacy of nicoradil in patients with stable angina. Cardiology. 2015 8 (55): 21-5. / REZVANOVA IU.A., Adamchik A.S. Otsenka AntiishemicHeskoi I Kardioprotektivnoi Effektivnosti Nikorandila U Patsientov So Stabil "Noi Stenokardiei. Kardiologiia. 2015 8 (55): 21-5.
23. Ryabikhin E.A., Mooseko M.E., Krasikovina Yua. and etc. Additional opportunities in the treatment of ischemic heart disease, complicated by chronic heart failure with a low fraction of emission of left ventricle. Heart failure. 2016; 17 (1): 3-9. / Riabikhin E.A., Mozheiko M.E., Krasil "nikova Iu.A. i dr. Dopolnitel" nye vozmozhnosti v lechenii ishemicheskoi bolezni serdtsa, oslozhnennoi khronicheskoi serdechnoi nedostatochnost "iu s nizkoi fraktsiei vybrosa levogo zheludochka. Serdechnaia nedostatochnost". 2016; 17 (1): 3-9.
24. Weisz G, G6N6REUX P, INIGUEZ A ET AL. For the River-PCI Investigators. Ranolazine in Patients After Percutaneous Coronary Intervention (River-PCI): A Multicentre, Randomised, Double-Blind, Placebo-Controlled Trial. Lancet 2016; 387: 136-45.
25. Alexander Ka, Weisz G, Prather K et al. Effects of Ranolazine on Angina and Quality of Life After Percutaneous Coronary Intervention Perecutaneous Revascularization feature from the Ranolazine for Incomplete Vessel Revascularization (River-PCI) Trial. Circulation 2016; 133: 39-47.
26. Takahashi J et al. Prognostic Impact of Chronic Nitrate Therapy in Patients with Vasospastic Angina: Multicentre Registry Study of The Japanese Coronary Spasm Association. EUR HEART J 2015; 36: 228-37. DOI: 10.1093 / EURHEARTJ / EHU313.
27. Boden We, O "ROURKE RA, TEO KK ET AL. Optimal Medical Therapy With or Without Pci for Stable Coronary Disease. N ENGL J MED 2007; 356: 1503-16.
28. Sedlis SP, Hartigan PM, TEO KK et al. For the Courage Trial Investigators. ORIGINAL EFFECT OF PCI ON LONG-TERM SURVIVAL IN PATIENTS WITH STABLE ISCHEMIC HEART DISEASE. N ENGL J MED 2015; 373: 1937-46.
29. 2014 ESC / EACTS Guidelines on Myocardial Revascularization. The Task Force On Myocardial Revascularization Of The European Society of Cardiology (ESC) And The European Association for Cardio-Thoracic Surgery (EACTS). EUR HEART J 2014. DOI: 10.1093 / EURHEARTJ / EHU2 78.
30. Kiramijyan S, Liu Mw. The Benefits of Drug-Eluting Stems in the Treatment of Coronary Artery Disease. RES REP CLIN CARDIOL 2016; 7: 9-25.
31. Bangalore S, Toklu B, Feit F. Outcomes with Coronary Arttery Bypass Graft Surgery Versus Percutaneous Coronary Intervention For Patients with Diabetes Mellitus: Can Newer Generation Drug-Eluting Stems Bridge The Gap? CIRC CARDIOVASC INTERV 2014; 7 (4): 518-25.
32. Campos CM, Christiansen EH, Stone GW, Serruys PW. The Excel and Noble Trials: Similarities, Contrasts and Future Perspectives for Left Main Revascularization. Euro Intervention 2015; 11 (Suppl. V): V115-V119.