The main groups of drugs for the treatment of ischemic heart disease. Drug treatment regimen

Ischemic heart disease (CHD) is one of the main causes of temporary and permanent disability of the population in the developed countries of the world. In this regard, the problem of ischemic heart disease occupies one of the leading places among the most important medical problems XXI century.

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

O modern methods treatment of coronary heart disease was told by Alexander Gorkov, head of the department of X-ray surgical methods of diagnosis and treatment of the District Cardiological Dispensary (Surgut, Khanty-Mansi Autonomous Okrug - Yugra).

Q: Alexander Igorevich, what is ischemic heart disease?

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

Q: Pain in the heart and nitroglycerin - the lot of older people?

Previously it was thought so, but now the younger generation is not spared from coronary heart disease. Many factors of modern reality play a role in this development of ischemic heart disease: ecology, hereditary predisposition, a lifestyle associated with smoking, physical inactivity and a diet rich in fats.

Q: What effective methods of treating coronary heart disease have appeared in the arsenal of cardiologists over the past decades?

The modern development of technology also accompanies the improvement of treatment methods, but its main principle remains the same - the restoration of blood flow through a narrowed or blocked coronary artery for normal myocardial nutrition. This can be achieved in two ways: medically and surgically.

Drug therapy modern drugs with a proven level of effectiveness today is the basic basis for the treatment of chronic coronary artery disease. Treatment is aimed at improving the patient's quality of life, that is, reducing the severity of symptoms, preventing the development of such forms of coronary artery disease as myocardial infarction, unstable angina pectoris, sudden cardiac death.

For this, the arsenal of cardiologists has various drugs, which reduce the content of "bad" cholesterol in the blood, which is responsible for the formation of plaques on the walls of blood vessels. In addition, in the treatment of coronary heart disease, drugs are used that need to be taken once a day: these are antiplatelet agents (thinning the blood), antiarrhythmic, antihypertensive and others. It should be noted that only a cardiologist can prescribe these medications based on the objective picture of the disease.

For more severe cases of ischemic heart disease, surgical techniques treatment. The most effective method endovascular surgery is considered to be the treatment of coronary artery disease. This relatively young direction of medicine has already won a solid position in the treatment of coronary artery disease. All interventions are performed without incisions, through a puncture under X-ray observation. These features are important for those patients who are contraindicated (due to concomitant diseases or general weakening of the body) traditional surgical intervention.

From the methods of endovascular surgery for coronary artery disease, balloon angioplasty and stenting are used, which allow to restore patency in the arteries affected by ischemia. The essence of the method is that a special balloon is inserted into the vessel, then it inflates and "pushes" aside atherosclerotic plaques or blood clots. After that, a cylindrical stent (wire structure made of a special alloy) is installed in the artery, which is able to maintain the shape given to the vessel.

Universally recognized and effective methodology operative blood flow in a narrowed or blocked artery is a coronary artery bypass grafting operation, when an artery blocked by a plaque or thrombus is replaced by an "artificial vessel" that takes over the blood flow. These operations are almost always performed on a non-working heart under cardiopulmonary bypass, for which there are clear indications.

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

Q: Alexander Igorevich, what is the reason for choosing the method used?

The state of human health, the degree of damage to the coronary arteries by atherosclerotic plaques or blood clots, and one of the important indicators is time! As part of the effective work in the Khanty-Mansi Autonomous Okrug - Ugra of the Yugra-Kor project, patients from all over the district in the first hours after the onset of pain syndrome get to one of the three Centers for interventional cardiology, including the District Cardiological Dispensary, and doctors manage to provide assistance with the use of surgical less traumatic methods... In 2012, about 1,100 angioplasty operations were performed at the cardiology center, of which about 300 - for patients with acute coronary syndrome within the framework of the Yugra-Kor project.

Q: Alexander Igorevich, tell us how the life of a person diagnosed with coronary heart disease should change?

The treatment of coronary artery disease involves the joint work of the cardiologist and the patient in several directions. First of all, you need to take care of lifestyle changes and the impact on the risk factors for coronary heart disease. This is quitting smoking, correcting cholesterol levels with diet or medication. A very important point not drug treatment CHD is the fight against a sedentary lifestyle by increasing physical activity sick. And, of course, preliminary treatment of concomitant diseases, if the development of ischemic heart disease occurs against their background.

Modern methods of treating coronary heart disease are quite effective in helping people live better and longer lives. But health is the daily result of a person's work on himself. Use your energies to preserve your own health and take care of the health of your heart!

Treatment of coronary heart disease involves a wide range of different measures, part of which is drug therapy. Diseases are treated according to special principles, which imply actions in several directions. With coronary artery disease, many drugs are used, each group of which is necessary to achieve a specific goal.

General principles of medical treatment of ischemic heart disease

At drug treatment ischemic heart disease must be used A complex approach... This allows you to achieve results in several directions at once.

Medical therapy for coronary artery disease is based on the following principles:

• relief of the manifestations of an already developed disease;
• preventing the progression of the disease;
• prevention of complications;
• normalization of lipid metabolism;
• normalization of blood clotting;
• improving the condition of the myocardium;
• normalization of pressure;
• increased exercise tolerance;
• taking into account the form of the disease and the patient's response to drugs of the same group;
• taking into account the complications that have developed: this usually refers to circulatory failure;
• accounting for concomitant diseases: more often it concerns diabetes mellitus, systemic atherosclerosis.

The approach to drug treatment for each patient should be individual. Many factors must be taken into account when prescribing medication, including the nuances of the course of the disease and individual characteristics sick.

Statins

This group of drugs is cholesterol-lowering. Their inclusion in the treatment of ischemic heart disease is necessary, since thanks to them, atherosclerotic plaques develop more slowly, shrink in size, and new ones are no longer formed.

The use of statins has a positive effect on the patient's life expectancy, the frequency and severity of cardiovascular attacks. Such drugs allow you to achieve the target cholesterol level of 4.5 mmol / L, while it is necessary to reduce the level of low-density lipoproteins to 2.5 mmol / L.

The effectiveness of statins is due to their interaction with the liver, where the production of an enzyme necessary for the production of cholesterol is inhibited. When decreasing general level cholesterol, its direct and reverse transport returns to normal.

With ischemic heart disease, they usually resort to the following drugs from the statin group:

• Atorvastatin;
• Lovastatin;
• Rosuvastatin;
• Simvastatin.

When treating coronary artery disease, statins are usually given in high dosages. For example, Rosuvastin is taken at 40 mg, and Atorvastatin is taken at 80 mg.

Antiplatelet agents

These drugs are needed to prevent blood clots. Under the influence of these medicines, the aggregation of platelets and erythrocytes is inhibited. As a result, their ability to stick together and adhere to the vascular endothelium is reduced.

By reducing the surface tension of erythrocyte membranes, their damage during passage through the capillaries is reduced. As a result, the blood flow is improved.

In the treatment of ischemic heart disease, acetylsalicylic acid is often used, which is the basis of Aspirin, Acecardol, Thrombolol. Such drugs are taken once a day at a dosage of at least 75 mg.

Another effective antiplatelet agent is Clopidogrel. Such drugs as Plavix, Clopidogrel are based on this substance. It is also taken once a day, 75 mg.

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

Antagonists of the renin-angiotensin-aldosterone system (ACE inhibitors)

The drugs of this group act on the angiotensin-converting enzyme, triggering a whole chain of reactions. The breakdown of bradykinin is slowed down, afterload and the production of angiotensin II, which constricts the vessels, decreases.

Due to this, ACE inhibitors provide several actions at once:

• hypotensive;
• nephroprotective;
• cardioprotective.

The use of ACE inhibitors in ischemic heart disease can achieve target blood pressure readings. When choosing a suitable drug, it is based on the ability of the active substance to penetrate into tissues. In the treatment of coronary artery disease, a remedy is selected that must be applied once a day. At the same time, it should be excreted in different ways in order to allow treatment against the background of renal or hepatic insufficiency.

Of the ACE inhibitors, they often resort to Captopril and. Only such drugs provide direct action when the rest of this group are prodrugs. The latter include, which is also often included in the treatment of coronary artery disease.

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

Angiotensin receptor blockers

Drugs in this group are usually prescribed for ischemic heart disease in the case when ACE inhibitors cannot be used due to the patient's individual intolerance to them. These drugs block angiotensin II receptors and are known by another name - sartans or angiotensin receptor antagonists.

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

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

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

The advantage of sartans is the minimal risk of side effects. This is especially true for dry cough, which often occurs while taking ACE inhibitors.

Beta-blockers

Drugs in this group act on β-adrenergic receptors. As a result, the heart rate decreases, which reduces the oxygen demand of the heart muscle.

The inclusion of β-blockers has a positive effect on the patient's life expectancy, and also reduces the likelihood of the frequency of cardiovascular events, including recurrent ones.

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

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

In the treatment of coronary artery disease, usually resort to, Carvedilol, Metoprolol. If the selected β-blocker is ineffective or its dosage cannot be increased, then it is combined with a nitrate or calcium antagonist. In some cases, a combination of all three is required. Additionally, an antianginal agent may be prescribed.

Nitrates

This group is represented by derivatives of glycerol, diglycerides, monoglycerides and triglycerides. As a result of exposure to nitrates, the contractile activity of vascular smooth muscles changes, and the preload on the myocardium decreases. This is ensured by vasodilation in the venous bed and blood deposition.

The use of nitrates causes a decrease in pressure. Such drugs are not prescribed if the pressure is not higher than 100/60 mm Hg. Art.

With ischemic heart disease, nitrates are mainly used to. There is no increase in survival with this treatment.

At high pressure seizures are stopped by intravenous drip of the drug. There is also a tablet and inhalation form.

Of the nitrates in the treatment of coronary heart disease, nitroglycerin or isosorbide mononitrate is usually resorted to. The patient is advised to carry the prescribed medication with him at all times. It is worth taking it with an attack of angina pectoris if the exclusion of the provoking factor does not help. Repeated intake of Nitroglycerin is allowed, but if there is no effect, then it should be called ambulance.

Cardiac glycosides

In CHD, drug therapy includes various antiarrhythmic drugs, one of the groups of which are cardiac glycosides. Their distinctive feature is vegetable origin.

The main purpose of cardiac glycosides is to treat heart failure. Taking such a drug leads to an increase in the efficiency of the myocardium, an improvement in its blood supply. The heart rate decreases, but their strength increases.

Cardiac glycosides are able to normalize arterial and lower venous pressure. These drugs are rarely prescribed for coronary artery disease because of the high risk adverse reactions.

Of the cardiac glycosides, they often resort to Digoxin or Korglikon. The first preparation is based on the woolly foxglove, the second on the May lily of the valley.

Calcium antagonists

Drugs in this group block calcium channels (L-type). Due to inhibition of the penetration of calcium ions, their concentration in cardiomyocytes and cells of smooth vascular muscles decreases. This ensures the expansion of the coronary and peripheral arteries, therefore, a pronounced vasodilator effect is observed.

The main purpose of slow blockers calcium channels with ischemic heart disease - prevention of angina attacks. Antianginal properties of this drug group resemble the properties of beta-blockers. Such drugs also lower the heart rate, provide an antiarrhythmic effect and suppress the contractility of the heart muscle.

In coronary artery disease, blockers of slow calcium channels are usually used if high blood pressure is combined with stable angina pectoris, as well as for the prevention of ischemia in patients with vasospastic angina pectoris.

The advantage of calcium antagonists over β-blockers lies in the possibility of use in a wide range of people, as well as in the case of contraindications or individual intolerance to beta-blockers.

Of the calcium antagonists in the treatment of coronary artery disease, they usually resort to Verapamil, Nifedipine, Diltiazem, Amlodipine, Felodipine.

Diuretics

Drugs in this group are diuretics. When using them, the excretion of water and salts in the urine increases, and the rate of urine formation increases. This leads to a decrease in the amount of fluid in the tissues.

This action allows the use of diuretics in order to lower blood pressure, as well as for edema against the background of cardiovascular pathologies.

With ischemic heart disease, thiazide or loop diuretics are used. In the first case, the drugs are potassium-sparing. Systematic therapy with drugs of this group reduces the risk of complications affecting cardiovascular system against the background of hypertension. Of the thiazide diuretics, they often resort to Indapamide or Hypothiazide. Such drugs are intended for long-term treatment - the required therapeutic effect is achieved after a month of continuous use of the drug.

Loop diuretics provide rapid and pronounced results. Usually they serve as an ambulance and help to carry out forced diuresis. Of this group, Furosemide is commonly used. It has a tablet and an injection form - the appropriate option is selected according to the circumstances.

Antihypoxants

Currently, such drugs are used quite rarely. Under their action, the utilization of oxygen, which circulates in the body, improves. As a result, resistance to oxygen starvation increases.

One of effective drugs from among antihypoxants - Actovegin. Its action is to activate the metabolism of glucose and oxygen. The medication also provides an antioxidant effect. Actovegin is used in high doses in acute myocardial infarction, as it provides the prevention of reperfusion syndrome. A similar effect is required when the patient has chronic heart failure, has undergone thrombolytic therapy or balloon angioplasty.

Another effective antihypoxant is Hypoxen. When taking such a drug, the tolerance of hypoxia increases, since mitochondria begin to consume oxygen faster, and the conjugation of oxidative phosphorylation increases. This drug is suitable for all types of oxygen deprivation.

Cytochrome C is also used. This enzyme agent catalyzes cellular respiration... The drug contains iron, which transforms into a reducing form and accelerates oxidative processes. The disadvantage of the drug is the risk allergic reactions.

Hypoxanths include Trimetazidine. This antianginal medication does not apply to standard schemes in the treatment of coronary heart disease, but can be used as an additional agent. Its action is to normalize cellular energy metabolism against the background of hypoxia and ischemia. In medical treatment for coronary artery disease, this drug is included as a prophylaxis for angina attacks. It is also indicated for patients with dizziness and tinnitus against the background of impaired cerebral circulation.

Anticoagulants

Medicines of this group affect the blood coagulation system, inhibiting its activity. As a result, the drug prevents blood clots.

In CHD, they usually resort to heparin, which is a direct anticoagulant. The anticoagulant activity of the drug is provided by the activation of antithrombin III. Due to certain reactions provided by heparin, antithrombin III becomes capable of inactivating coagulation factors, kallikrein, and serine proteases.

In case of ischemic heart disease, the drug can be administered subcutaneously (abdominal area) or intravenously through an infusion pump. In myocardial infarction, this drug is prescribed to prevent blood clots. In this case, resort to subcutaneous administration funds in the amount of 12,500 IU. This procedure is repeated every day for a week. If the patient is in the intensive care unit, then heparin is administered by an infusomat.

Warfarin is also used for ischemic heart disease. This drug is an anticoagulant indirect action... It is usually prescribed if the patient is diagnosed with a permanent form of atrial fibrillation. The dosage of the medication is selected in such a way that blood clotting is kept at the level of 2-3.

Warfarin provides active dissolution of blood clots, but can lead to bleeding. This drug can only be used when prescribed by a doctor. It is imperative to monitor blood tests during treatment.

Antiplatelets

Antithrombotic therapy for ischemic heart disease is prescribed for both acute and chronic course. Drugs in this group can inhibit platelet function. They affect the hemocoagulation system, restore vascular patency against the background of their thrombolysis.

One of the effective antiplatelets is Dipyridamole, which is a pyrimido-pyrimidine derivative. It has vasodilating and antiplatelet properties. Usually this drug is prescribed to be taken twice a day. Against the background of ischemic brain disease, the medication is combined with small doses of aspirin.

The main representatives of antiplatelets are Aspirin and Clopidogrel. Against the background, Aspirin is prescribed, and if there are contraindications, they resort to the second option.

Non-steroidal anti-inflammatory drugs

Non-steroidal anti-inflammatory drugs differ a wide range application and complex action. These drugs have analgesic, anti-inflammatory and antipyretic properties.

The advantage of NSAIDs is high safety and low toxicity. The risk of complications is low, even with high doses of these drugs.

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

Anti-inflammatory non-steroidal drugs reduce vascular permeability, increase microcirculation in them.

One of the most famous drugs in this group is Aspirin. With ischemic heart disease, the patient is prescribed a lifelong intake of this medication, if there are no contraindications to such treatment.

Diclofenac and Ibuprofen are well-known representatives of the non-steroidal anti-inflammatory group. The use of such drugs for myocardial infarction is not recommended, as it negatively affects the prognosis. The approach is similar for conditions equivalent to a heart attack.

Drug therapy for ischemic heart disease involves the use of a whole range of drugs. Each of them provides a specific result. A competent combination of different medications for a particular patient must be determined on an individual basis. This can only be done by a specialist.

Treatment for coronary heart disease primarily depends on clinical form... For example, although some general principles of treatment are used for angina pectoris and myocardial infarction, nevertheless, the tactics of treatment, the selection of the mode of activity and specific drugs can be radically different. However, some general directions important for all forms of ischemic heart disease.

1. Restriction of physical activity. With physical exertion, the load on the myocardium increases, and as a result, the demand of the myocardium for oxygen and nutrients. If the blood supply to the myocardium is disturbed, this need is not satisfied, which actually leads to manifestations of ischemic heart disease. Therefore, the most important component of the treatment of any form of ischemic heart disease is the limitation of physical activity and its gradual increase during rehabilitation.

2. Diet. With ischemic heart disease, in order to reduce the load on the myocardium in the diet, the intake of water and sodium chloride (table salt) is limited. In addition, given the importance of atherosclerosis in pathogenesis of ischemic heart disease, great attention focuses on limiting foods that contribute to the progression of atherosclerosis. An important component of the treatment of coronary artery disease is the fight against obesity as a risk factor.

The following food groups should be limited or, if possible, discarded.

Animal fats (lard, butter, fatty meats)

Fried and smoked food.

Products containing a large number of salt ( salted cabbage, salty fish etc)

Limit high-calorie food intake, especially fast-absorbing carbohydrates. (chocolate, sweets, cakes, pastry).

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

3. Pharmacotherapy for ischemic heart disease. There are a number of groups of drugs that can be indicated for use in one form or another of ischemic heart disease. In the USA, there is a formula for the treatment of coronary artery disease: "A-B-C". It involves the use of a triad of drugs, namely antiplatelet agents. -adrenergic blockers and cholesterol-lowering drugs.

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

- Antiplatelet agents (A). Antiplatelet agents prevent the aggregation of platelets and erythrocytes, reduce their ability to adhere and adhere to the vascular endothelium. Antiplatelet agents facilitate the deformation of red blood cells when passing through the capillaries, improve blood flow.

Aspirin - taken once a day at a dose of 100 mg, if you suspect the development of myocardial infarction, a single dose can reach 500 mg.

Clopidogrel - taken 1 time per day, 1 tablet 75 mg. Required admission within 9 months after performing endovascular interventions and CABG.

-? -Adrenergic blockers (B). Due to the action on? -Arenoreceptors, adrenergic blockers reduce the heart rate and, as a result, myocardial oxygen consumption. Independent randomized studies confirm an increase in life expectancy when taking β-blockers and a decrease in the frequency of cardiovascular events, including repeated ones. It is currently impractical to use the drug atenolol, as it does not improve the prognosis according to randomized trials. -adrenergic blockers are contraindicated in case of concomitant pulmonary pathology, bronchial asthma, COPD. Below are the most popular β-blockers with proven properties of improving the prognosis in coronary artery disease.

Metoprolol (Betalok Zok, Betalok, Egilok, Metocard, Vasokardin);

Bisoprolol (Concor, Coronal, Bisogamma, Biprol);

Carvedilol (Dilatrend, Talliton, Coriol).

- Statins and Fibrates (C). Cholesterol-lowering drugs are used to reduce the rate of development of existing atherosclerotic plaques and prevent the emergence of new ones. Proven positive influence for life expectancy, these drugs also reduce the frequency and severity of cardiovascular events. The target cholesterol level in patients with coronary artery disease should be lower than in people without coronary artery disease, and equal to 4.5 mmol / l. The target level of LDL in patients with coronary artery disease is 2.5 mmol / l.

Lovastatin;

Simvastatin;

Atorvastatin;

Rosuvastatin (the only drug that reliably reduces the size of atherosclerotic plaque);

Fibrates. They belong to a class of drugs that increase the anti-atherogenic fraction of HDL, with a decrease in which mortality from coronary heart disease increases. They are used to treat dyslipidemia IIa, IIb, III, IV, V. They differ from statins in that they mainly reduce triglycerides (VLDL) and can increase the HDL fraction. Statins predominantly lower LDL and have no significant effect on VLDL and HDL. Therefore, for maximum effective treatment macrovascular complications require a combination of statins and fibrates. When using fenofibrate, mortality from coronary heart disease is reduced by 25%. Of the fibrates, only fenofibrate is safely combined with all classes of statins (FDA).

Fenofibrate

Other classes: omega-3 polyunsaturated fatty acids (Omacor). In case of ischemic heart disease, they are used to restore the phospholipid layer of the cardiomyocyte membrane. Restoring the structure of the cardiomyocyte membrane, Omakor restores the basic (vital) functions of heart cells - conduction and contractility, which were impaired as a result of myocardial ischemia.

Nitrates. There are nitrates for injection.

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

Nitrates predominantly act on the venous wall, reducing the preload on the myocardium (by dilating the vessels of the venous bed and depositing blood). A side effect of nitrates is lower blood pressure and headaches. It is not recommended to use nitrates at blood pressure below 100/60 mm Hg. Art. In addition, it is currently reliably known that taking nitrates does not improve the prognosis of patients with coronary artery disease, that is, does not lead to an increase in survival, and is currently used as a drug for relieving symptoms of angina pectoris. Intravenous drip of nitroglycerin allows you to effectively combat the symptoms of angina pectoris, mainly against the background of high blood pressure numbers.

Nitrates exist in both injectable and tablet forms.

Nitroglycerine;

Isosorbide mononitrate.

Anticoagulants. Anticoagulants inhibit the appearance of fibrin filaments, they prevent the formation of blood clots, help stop the growth of blood clots that have already arisen, increase the effect on blood clots 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 clots more slowly).

Heparin is injected under the skin of the abdomen or intravenously using an infusion pump. Myocardial infarction is an indication for the appointment of heparin prophylaxis of blood clots, heparin is prescribed in a dose of 12,500 IU, injected under the skin of the abdomen daily for 5-7 days. In the ICU, heparin is administered to the patient using an infusion pump. An instrumental criterion for the appointment of heparin is the presence of depression of the S-T segment on the ECG, which indicates acute process... This feature is important in terms of differential diagnosis, for example, in cases where the patient has ECG signs previous heart attacks.

Diuretics Diuretics are designed to reduce the load on the myocardium by reducing the volume of circulating blood due to the accelerated elimination of fluid from the body.

Loopback. The drug "Furosemide" in tablet form.

Loop diuretics reduce the reabsorption of Na +, K +, Cl- in the thick ascending part of Henle's loop, thereby reducing reabsorption ( reverse suction) water. Have a fairly pronounced quick action, as a rule, are used as emergency drugs (for the implementation of forced diuresis).

The most common drug in this group is furosemide (lasix). Available in injectable and tablet forms.

Thiazide. Thiazide diuretics are a Ca2 + sparing diuretic. By reducing the reabsorption of Na + and Cl- in the thick segment of the ascending part of the loop of Henle and the initial part of the distal tubule of the nephron, thiazide drugs reduce urine reabsorption. With the systematic use of drugs of this group, the risk of cardiovascular complications decreases in the presence of concomitant hypertension.

Hypothiazide;

Indapamide.

Angiotensin-converting enzyme inhibitors. Acting on the angiotensin-converting enzyme (ACE), this group of drugs blocks the formation of angiotensin II from angiotensin I, thus preventing the realization of the effects of angiotensin II, that is, leveling vasospasm. This ensures that the target blood pressure figures are maintained. Drugs in this group have a nephro- and cardioprotective effect.

Enalapril;

Lisinopril;

Captopril.

Antiarrhythmic drugs. The drug "Amiodarone" is available in tablet form.

Amiodarone belongs to the III group of antiarrhythmic drugs, has a complex antiarrhythmic effect. This drug acts on the Na + and K + channels of cardiomyocytes, and also blocks α and β adrenergic receptors. Thus, amiodarone has antianginal and antiarrhythmic effects. According to randomized clinical trials, the drug increases the life expectancy of patients who regularly take it. When taking tablet forms of amiodarone, the clinical effect is observed after about 2-3 days. Maximum effect achieved after 8-12 weeks. This is due to the long half-life of the drug (2-3 months). Due to this this drug it is used in the prevention of arrhythmias and is not an emergency aid.

Taking into account these properties of the drug, the following scheme of its use is recommended. During the saturation period (the first 7-15 days), amiodarone is prescribed in daily dose 10 mg / kg of the patient's weight in 2-3 doses. 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 until a maintenance dose of 200 mg per day is reached.

Other groups of drugs.

Ethylmethylhydroxypyridine

The drug "Mexidol" in tablet form. Metabolic cytoprotector, antioxidant-antihypoxant, with a complex effect on the key links of pathogenesis cardiovascular disease: anti-atherosclerotic, anti-ischemic, membrane-protective. In theory, ethylmethylhydroxypyridine succinate has significant beneficial effects, but there is currently no evidence of clinical efficacy based on independent, randomized, placebo-controlled trials.

Mexicor;

Coronater;

Trimetazidine.

4. The use of antibiotics for ischemic heart disease. There are results of clinical observations of the comparative effectiveness of two different courses of antibiotics and placebo in patients admitted to the hospital or with acute heart attack myocardium, or with unstable angina. Studies have shown the effectiveness of a number of antibiotics in the treatment of coronary artery disease.

The effectiveness of this type of therapy is not pathogenetically substantiated, and this technique is not included in the standards for the treatment of coronary artery disease.

5. Endovascular coronary angioplasty. The use of endovascular (translucent, transluminal) interventions (coronary angioplasty) is developing in different forms Ischemic heart disease. These include balloon angioplasty and coronary angiography-guided stenting. In this case, the instruments are inserted through one of the large arteries (in most cases, the femoral artery is used), and the procedure is performed under fluoroscopy control. In many cases, such interventions help prevent the development or progression of myocardial infarction and avoid open surgery.

A separate area of ​​cardiology - interventional cardiology - deals with this area of ​​ischemic heart disease treatment.

6. Surgical treatment.

Coronary artery bypass grafting is performed.

With certain parameters of coronary heart disease, there are indications for coronary artery bypass grafting - an operation in which the blood supply to the myocardium is improved by connecting coronary vessels below the site of their defeat with external vessels. The best known is coronary artery bypass grafting (CABG), in which the aorta is connected to the segments of the coronary arteries. For this, autografts (usually a large saphenous vein) are often used as shunts.

It is also possible to use balloon dilatation of blood vessels. In this operation, the manipulator is inserted into the coronary vessels through the puncture of the artery (usually femoral or radial), and the vessel lumen is expanded by means of a balloon filled with a contrast agent; the operation is, in fact, bougienage of the coronary vessels. Currently, "pure" balloon angioplasty without subsequent stent implantation is practically not used, due to the low efficiency in the long term.

7. Other non-drug treatments

- Hirudotherapy. Hirudotherapy is a method of treatment based on the use of the antiplatelet properties of leech saliva. This method is an alternative method and has not been clinically tested for compliance. evidence-based medicine... Currently in Russia it is used relatively rarely, is not included in the standards of medical care for coronary artery disease, it is used, as a rule, at the request of patients. Potential positive effects this method are in the prevention of thrombus formation. It should be noted that when treated according to approved standards, this task is performed using heparin prophylaxis.

- Method of shock wave therapy. Exposure to low power shock waves leads to myocardial revascularization.

An extracorporeal source of a focused acoustic wave allows a remote effect on the heart, causing "therapeutic angiogenesis" (vascular formation) in the zone of myocardial ischemia. The effect of SWT has a double effect - short-term and long-term. First, the vessels dilate and blood flow improves. But the most important thing begins later - new vessels appear in the affected area, which provide long-term improvement.

Low-intensity shock waves induce shear stress in the vascular wall. This stimulates the release of vascular growth factors, triggering the growth of new vessels that feed the heart, improving myocardial microcirculation and reducing the symptoms of angina pectoris. Theoretically, the results of such treatment are a decrease in the functional class of angina pectoris, an increase in exercise tolerance, a decrease in the frequency of attacks and the need for drugs.

However, it should be noted that at present there have been no adequate independent multicenter randomized studies evaluating the effectiveness of this technique. Studies cited as evidence of the effectiveness of this technique are usually carried out by the manufacturers themselves. Or do not meet the criteria of evidence-based medicine.

This method has not become widespread in Russia due to the questionable efficiency, high cost of equipment, and the lack of appropriate specialists. In 2008, this method was not included in the standard of medical care for coronary artery disease, and the implementation of these manipulations was carried out on a contractual commercial basis, or in some cases under voluntary medical insurance contracts.

- Use of stem cells. When using stem cells, those performing the procedure expect that the pluripotent stem cells introduced into the patient's body will differentiate into missing myocardial cells or vascular adventitia. It should be noted that stem cells actually possess this ability, but at present the level of modern technologies does not allow differentiating a pluripotent cell into the tissue we need. The cell itself makes the choice of the differentiation path - and often not the one that is needed for the treatment of ischemic heart disease.

This method of treatment is promising, but has not yet been clinically tested and does not meet the criteria of evidence-based medicine. It takes years of research and development to deliver the benefits that patients expect from pluripotent stem cells.

Currently, this method of treatment is not used in official medicine and is not included in the standard of care for coronary artery disease.

- Quantum therapy for coronary artery disease. It is a therapy by exposure to laser radiation. The effectiveness of this method has not been proven, an independent clinical study has not been conducted.

Modern aspects of drug treatment of chronic coronary artery disease

V last years the understanding of the mechanisms of development of atherosclerosis and chronic ischemic heart disease has significantly expanded and there has been significant progress in the field of drug treatment of these patients. To date, there are 2 directions in the treatment of chronic coronary artery disease: 1. improving the prognosis of life; 2.improving the patient's quality of life: reducing angina attacks and myocardial ischemia, increasing tolerance physical activity... But it is becoming more and more obvious that in the early stages therapeutic effects it is extremely important to influence the prevention of damage to the vascular wall (atherosclerosis) by maximally modifying the risk factors for the disease (1).

Authors:

Medicines that improve the prognosis in patients with chronic coronary artery disease

Antiplatelet drugs (antiplatelet agents) (acetylsalicylic acid - ASA, clopidogrel) are mandatory means of treating patients with chronic ischemic heart disease. Aspirin remains the basis for the prevention of arterial thrombosis and is indicated at a dose of 75-150 mg / day. Its effect on the degree of vascular risk has been demonstrated in a number of large-scale controlled studies. Thus, the risk of myocardial infarction in patients with stable angina pectoris decreased by an average of 87% with long-term (up to 6 years) ASA intake. After myocardial infarction, mortality decreases by 15%, the incidence of repeated myocardial infarction - by 31%. Long-term use of antiplatelet agents is justified in all patients who do not have obvious contraindications to these drugs - peptic ulcer stomach, diseases of the blood system, hypersensitivity, etc. Additional safety is provided by preparations of acetylsalicylic acid, coated with an enteric coating, or antacids (magnesium hydroxide). Clopidogrel (a non-competitive blocker of ADP receptors) is an alternative to ASA, does not have a direct effect on the gastric mucosa, and is less likely to cause dyspeptic symptoms. But sharing inhibitors gastric secretion(esomeprazole) and ASA (80 mg / day) are more effective in preventing recurrent ulcer bleeding in patients with ulcers than switching 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 stable angina pectoris therapy with two drugs is not justified. If you need to take non-steroidal anti-inflammatory drugs, you should not cancel aspirin.

Lipid-lowering drugs. Currently, the most effective cholesterol-lowering drugs are statins. The indication for taking statins in patients with coronary artery disease is the presence of hyperlipidemia with insufficient effect of diet therapy. Along with the hypolipidemic effect, they help stabilize atherosclerotic plaques, reduce their tendency to rupture, improve endothelial function, reduce the tendency of coronary arteries to spastic reactions, and suppress inflammatory reactions. Statins have a positive effect on a number of indicators that determine the tendency to thrombus formation - blood viscosity, platelet and erythrocyte aggregation, fibrinogen concentration. These drugs reduce the risk of atherosclerotic cardiovascular complications in both primary and secondary prevention. In stable angina pectoris, a decrease in mortality under the influence of simvastatin (studies 4S, HPS), pravastatin (PPPP, PROSPER), atorvastatin (ASCOT-LLA) has been proven. The results of treatment with statins are similar in patients with different serum cholesterol levels, including "normal" ones. That. Decisions on statin therapy depend not only on cholesterol levels, but also on the level of cardiovascular risk. In modern European recommendations, the target level of total cholesterol in patients with coronary artery disease and high-risk patients is £ 4.5 mmol / L and LDL cholesterol £ 2.0 mmol / L. Statin therapy should be ongoing because already one month after stopping the drug intake, the blood lipid level returns to the initial one. With the ineffectiveness of reducing the levels of total cholesterol and LDL cholesterol to the target values, the dose of statin is increased, observing an interval of 1 month (during this period, the greatest effect of the drug is achieved). With the use of statins, the level of triglycerides is usually slightly reduced (by 6-12%) and the level of HDL-cholesterol in the blood plasma is increased (by 7-8%). Patients with low HDL cholesterol, elevated triglyceride levels, diabetes mellitus or metabolic syndrome are shown to prescribe fibrates. Perhaps the joint appointment of statins and fibrates (primarily fenofibrate), however, it is necessary to regularly monitor the level of CPK in the blood.

β-blockers. In the absence of contraindications, β-blockers are prescribed to all patients with coronary artery disease, especially after myocardial infarction. The main goal of therapy is to improve the long-term prognosis of a patient with coronary artery disease. β-blockers significantly improve the prognosis of patients' life even in the case when ischemic heart disease is complicated by heart failure. Obviously, preference should be given to selective β-blockers (fewer contraindications and side effects) (atenolol, metoprolol, bisoprolol, nebivolol, betaxolol), with prolonged action drugs. The basic principles of prescribing β-blockers are to maintain a resting heart rate within 55-60 beats per minute. In this case, a blockade of β-receptors occurs.

ACE inhibitors. It is well known that the use of ACE inhibitors in patients after myocardial infarction with signs of heart failure or impaired left ventricular function contributes to a significant decrease in mortality and the likelihood of repeated myocardial infarction. The absolute indications for the appointment of an ACE inhibitor in chronic coronary artery disease are signs of heart failure and myocardial infarction. In cases of poor tolerance of these drugs, angiotensin receptor antagonists (primarily candesartan, valsartan) are prescribed. ACE inhibitors affect the main pathological processes - vasoconstriction, structural changes in the vascular wall, left ventricular remodeling, the formation of a blood clot underlying coronary heart disease. The protective effect of ACE inhibitors against the development of atherosclerosis, apparently, is due to a decrease in the level of angiotensin II, an increase in the production of nitric oxide, and an improvement in the function of the vascular endothelium. In addition, the drugs carry out vasodilation peripheral vessels, as well as coronary arteries, potentiate the effects of nitrovasodilators, contributing to a decrease in tolerance to them.

Recently, there has been evidence of the effectiveness of some ACE inhibitors in patients with coronary artery disease with normal function LV and blood pressure... Thus, the HOPE and EUROPA study demonstrated the positive effect of ramipril and perindopril on the likelihood of cardiovascular complications. But other ACE inhibitors (quinapril, trandolapril), respectively, in the QUIET and PEACE studies, did not show a clear effect on the course of ischemic heart disease (i.e., this property is not a class effect). The results of the EUROPA study (2003) deserve special attention. According to the results of this study, in patients who took perindopril (8 mg) for 4.2 years, the total risk of all-cause mortality, non-fatal myocardial infarction, unstable angina was reduced by 20%, the number of fatal myocardial infarctions - by 24%. The need for hospitalization due to the development of heart failure decreased significantly (by 39%). That. the use of ACE inhibitors is advisable in patients with angina pectoris with arterial hypertension, diabetes mellitus, heart failure, asymptomatic left ventricular dysfunction or myocardial infarction.

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

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

1. Fibrates with low HDL or high triglycerides in patients with diabetes mellitus or metabolic syndrome (B).

Note: Class I - reliable evidence and (or) consensus of experts that this type of treatment is useful and effective, Class IIa - evidence and (or) expert opinions for benefit / effectiveness prevail, Class IIb - benefit / effectiveness is not well confirmed evidence and (or) expert opinions.

Evidence level A: Evidence obtained from multicenter, randomized clinical or metoanalysis. Evidence level B: Evidence from one randomized clinical research or large, non-randomized trials.

Drug therapy aimed at relieving symptoms of chronic coronary artery disease

Modern treatment of ischemic heart disease includes a number of antianginal and anti-ischemic drugs and metabolic agents. They are aimed at improving the quality of life of patients by reducing the frequency of angina attacks and eliminating myocardial ischemia. Successful antianginal treatment is considered in the case of complete or almost complete elimination of angina attacks and the patient's return to normal activity (angina pectoris no more than I FC) and with minimal side effects therapy (3,4). In the treatment of chronic ischemic heart disease, 3 main groups of drugs are used: β-blockers, organic nitrates, calcium antagonists.

β-blockers. These drugs are used in chronic coronary artery disease in 2 directions: they improve the prognosis, as mentioned above, and have a pronounced antianginal effect. Indications for the use of β-blockers are the presence of angina pectoris, especially in combination with arterial hypertension, concomitant heart failure, silent myocardial ischemia, myocardial ischemia with concomitant disorders heart rate... In the absence of direct contraindications, β-blockers are prescribed to all patients with coronary artery disease, especially after myocardial infarction. When treating with β-blockers, it is important to control hemodynamics, achieve target heart rate levels, if necessary, reduce the doses of drugs, but not cancel if heart rate at rest occurs<60 ударов в минуту. Следует также помнить о возможности развития синдрома отмены, в связи с чем β-адреноблокаторы необходимо отменять постепенно.

Organic nitrates (preparations of nitroglycerin, isosorbide dinitrate and isosorbide 5-mononitrate) are used to prevent angina attacks. These drugs provide hemodynamic unloading of the heart, improve blood supply to ischemic areas and increase exercise tolerance. However, with regular intake of nitrates, addiction can develop (the antianginal effect can weaken or even disappear). To avoid this, nitrates are prescribed only intermittently with a drug-free time of at least 6-8 hours per day. Schemes for the appointment of nitrates are different and depend on the functional class of angina pectoris. So, for angina pectoris, for example, FC I, nitrates are prescribed only intermittently in short-acting dosage forms - sublingual tablets, aerosols of nitroglycerin and isosorbide dinitrate. They should be used 5-10 minutes before the expected physical activity, which usually causes angina attacks. With angina pectoris II FC, nitrates are also prescribed intermittently, before the expected physical activity in the form of dosage forms of short or moderately prolonged action. With angina pectoris III FC, 5-mononitrates of prolonged action with a nitrate-free period of 5-6 hours are more often used. With angina pectoris IV FC, when angina attacks can occur at night, nitrates should be prescribed so as to ensure their round-the-clock effect, usually in combination with other antianginal drugs.

Molsidomin has a nitrate-like effect. The drug reduces vascular wall tension, improves collateral circulation in the myocardium and has antiaggregatory properties. Available in doses of 2 mg (comparable to isosorbide dinitrate 10 mg), 4 mg and retard form 8 mg (duration of action 12 hours). An important point is the indication for the appointment of nitrates and molsidomine - the presence of confirmed myocardial ischemia.

Calcium antagonists (AAs), along with pronounced antianginal (anti-ischemic) properties, can have an additional antiatherogenic effect (stabilization of the plasma membrane, which prevents the penetration of free cholesterol into the vessel wall), which makes it possible to prescribe them more often to patients with chronic coronary artery disease with lesions of arteries of various other localization.

Both subgroups of AA have antianginal action - dihydropyridines (primarily nifedipine and amlodipine) and nondihydropyridines (verapamil and diltiazem). The mechanism of action of these subgroups is different: in the properties of dihydropyridines, peripheral vasodilation prevails, in the actions of nondihydropyridines - negative chrono- and inotropic effects.

The undoubted advantages of AK are a wide range of their pharmacological effects aimed at eliminating the manifestations of coronary insufficiency - antianginal, hypotensive, antiarrhythmic effects. This therapy has a beneficial effect on the course of atherosclerosis. Anti-atherosclerotic properties have already been demonstrated for amlodipine in the PREVENT study (5). In patients with various forms of coronary artery disease, verified by quantitative coronary angiography, amlodipine significantly slowed down the progression of atherosclerosis in the carotid arteries: according to the results of ultrasound examination, the wall thickness of the carotid artery decreased by 0.0024 mm / year (p = 0.013). After 3 years of treatment, the frequency of re-hospitalizations due to deterioration of the condition was 35% less, the need for myocardial revascularization operations - by 46%, the frequency of all clinical complications - by 31%. The results of the study seem to be extremely important, since the indicator "intima / media thickness of the carotid arteries" is an independent predictor of the development of myocardial infarction and cerebral stroke (6). In the MDPIT study, the administration of diltiazem to 2466 patients significantly reduced the risk of recurrent myocardial infarction, but did not affect overall mortality (7). The studies devoted to the study of the effect of long-acting nifedipine and amlodipine on impaired endothelium-dependent vasodilation of the coronary arteries (ENCORE I and II and CAMELOT) have been completed.

Nevertheless, today AK represent a very important class of drugs for the treatment of coronary artery disease. In accordance with the recommendations of the European Society of Cardiology and the American College of Cardiology, AK are a mandatory component of antianginal therapy for stable angina pectoris - both as monotherapy (in the case of contraindications to β-blockers) and in the form of combination therapy in combination with β-blockers and nitrates. AK is especially indicated for patients with vasospastic angina and episodes of painless ischemia. AK in chronic ischemic heart disease should be predominantly prescribed in the form of drugs of the second generation - dosage forms of prolonged action, used once a day. According to controlled studies, the doses of AA recommended for stable angina pectoris are 30-60 mg / day for nefidipine, 240-480 mg / day for verapamil, and 5-10 mg / day for amlodipine (8). It should be remembered that the appointment of verapamil and diltiazem is contraindicated in the presence of signs of heart failure, while amlodipine can be prescribed in these circumstances without any consequences (9).

Other antianginal drugs

These include, first of all, various metabolic drugs. Currently, the anti-ischemic and antianginal efficacy of trimetazidine has been proven. Indications for its use: ischemic heart disease, prevention of angina attacks with long-term treatment. Trimetazidine can be prescribed at any stage of therapy for stabilizing angina pectoris to enhance antianginal efficacy. But there are a number of clinical situations when trimetazidine can be the drug of choice: in elderly patients, with circulatory failure of ischemic genesis, sick sinus syndrome, with intolerance to antianginal hemodynamic drugs, as well as with restrictions or contraindications to their appointment.

Recently, a new class of antianginal drugs has been created - sinus node If flow inhibitors. Their only representative, ivabradine (Coraxan, Les laboratories Servier) has a pronounced antianginal effect due to an exclusive decrease in heart rate and lengthening of the diastole phase, during which myocardial perfusion occurs (10). When treated with Coraxan, the total duration of the stress test increases by 3 times, even in patients who are already taking β-blockers. (eleven). According to the results of the recently reported BEAUTIFUL study, Coraxan significantly reduces the risk of myocardial infarction by 36% (p = 0.001) and the need for revascularization by 30% (p = 0.016) in patients with coronary artery disease and heart rate over 70 beats per minute (12). Currently, the range of use of this drug has expanded: it is a chronic coronary artery disease with both preserved function of the left ventricle and its dysfunction.

1. Short-acting nitroglycerin for angina relief and situational prophylaxis (patients should receive adequate instructions for the use of nitroglycerin) (B).
2. β1-blockers of prolonged action with dose titration to the maximum therapeutic (A).
3. With poor tolerance or low efficacy of a β-blocker, monotherapy with calcium antagonists (A), prolonged nitrates (C).
4. In case of insufficient effectiveness of monotherapy with β-blockers, the addition of calcium antagonists (B).

1. In case of poor tolerance of β-blockers, prescribe an If inhibitor of sinus node channels - ivabradine (B).
2. If monotherapy with calcium antagonists or combination therapy with calcium antagonists and β-blockers is ineffective, replace the calcium antagonist with prolonged nitrate (C).

1. Metabolic drugs (trimetazidine) as an addition to standard therapy or as an alternative to them with poor tolerance (B).

Note: Level of Evidence C: Opinion from a number of experts and / or results of small studies, retrospective analyzes.

Outpatient management of patients with stable coronary artery disease

During the first year of the disease, with a stable condition of the patient and good tolerance of drug treatment, it is recommended to assess the condition of patients every 4-6 months, then, with a stable course of the disease, it is quite enough to conduct an outpatient examination once a year (more often according to indications). With careful individual selection of doses of antianginal drugs, a significant antianginal effect can be achieved in more than 90% of patients with stable angina pectoris II-III FC. To achieve a more complete antianginal effect, combinations of different antianginal drugs are often used (β-blockers and nitrates, β-blockers and dihydropyridine AAs, non-dihydropyridine AAs and nitrates) (13). However, with the combined administration of nitrates and dihydropyridine calcium antagonists in 20-30% of patients, the antianginal effect decreases (compared with the use of each drug separately), while the risk of side effects increases. It has also been shown that the use of 3 antianginal drugs may be less effective than treatment with class 2 drugs. Before prescribing the second drug, the dose of the first should be increased to the optimal level, and before the combination therapy with 3 drugs, it is necessary to test various combinations of 2 antianginal agents.

Special situations: Syndrome X and vasospastic angina

Syndrome X treatment . In about half of the patients, nitrates are effective, so it is advisable to start therapy with this group of drugs. If the treatment is ineffective, AK and β-blockers can be added. ACE inhibitors and statins reduce the severity of endothelial dysfunction and manifestations of ischemia during exercise, so they should be used in this group of patients. Metabolic therapy is also used in the complex treatment. To achieve a stable therapeutic effect in patients with syndrome X, an integrated approach is required using antidepressants, aminophylline (aminophylline), psychotherapy, electrical stimulation methods and physical training.

1. Treatment with nitrates, β-blockers 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 antianginal drugs, including metabolites (C)

1, Aminophylline with persistence of pain despite the implementation of class I recommendations (C)

2. Imipramine with persistence of pain, despite the implementation of the recommendations of class I (C).

Treatment of vasospastic angina pectoris. It is important to eliminate factors that contribute to the development of vasospastic angina, such as smoking, stress. The treatment is based on nitrates and AA. At the same time, nitrates are less effective in preventing resting angina attacks. Calcium antagonists are more effective in treating coronary spasm. It is advisable to use nifedipine retard at a dose of 120 mg / day, verapamil up to 480 mg / day, diltiazem up to 360 mg / day. Combined therapy with prolonged nitrates and AK in most patients leads to remission of vasospastic angina pectoris. Within 6-12 months after the cessation of angina attacks, the doses of antianginal drugs can be gradually reduced.

1. Treatment with calcium antagonists and nitrates according to indications in patients with normal angiograms or non-stenotic coronary artery disease (B).

Currently, in the arsenal of a doctor for the treatment of angina pectoris there is a complex of anti-ischemic, antithrombotic, hypolipidemic, cytoprotective and other drugs, which, with their differentiated prescription, greatly increases the effectiveness of treatment and improves the survival rate of patients with coronary artery disease.

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 pectoris Recommendations of the special commission of the European Society of Cardiology. / Russian honey. Journal.-1998.-Volume 6, No. 1.-3-28.
4. Gurevich M.A. Chronic ischemic (coronary) heart disease. Guidelines for physicians.-M. 2003.- 192s.
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-artery 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. T.E. Morozova Modern aspects of pharmacotherapy of ischemic 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, multicentered, 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 artery disease and left ventricular systolic dysfunction: a rabdomised, double-blind, placebo-controlled trial // Lancet. 2008.-1-10.
13. Diagnostics and treatment of stable angina pectoris (recommendations) .- Minsk, 2006.- 39 p.

IHD: treatment, prevention and prognosis

Treatment of cardiac ischemia depends on the clinical manifestations of the disease. The tactics of treatment, the intake of certain medications and the selection of the mode of physical activity can vary greatly for each patient.

The course of treatment for cardiac ischemia includes the following complex:

• therapy without the use of medications;
• therapy with medications;
• endovascular coronary angioplasty;
• treatment with surgery;
• other treatments.

Drug treatment of cardiac ischemia involves the patient taking nitroglycerin, which is capable of stopping angina attacks in a short time due to the vasodilating effect.

This also includes taking a number of other medications, which are prescribed exclusively by the attending specialist. For their appointment, the doctor relies on the data obtained in the process of diagnosing the disease.

Drugs used in treatment

Theoapia for coronary heart disease involves taking the following drugs:

• Antiplatelet agents... These include acetylsalicylic acid and clopidogrel. The drugs, as it were, "thin" the blood, helping to improve its fluidity and reducing the ability of platelets and erythrocytes to adhere to blood vessels. They also improve the passage of red blood cells.
• Beta-blockers... This is metoprolol. carvedilol. bisoprolol. Drugs that reduce the heart rate of the myocardium, which leads to the desired result, that is, the myocardium receives the required volume of oxygen. They have a number of contraindications: chronic lung disease, pulmonary insufficiency, bronchial asthma.
• Statins and fibrators... These include lovastatin. fenofibate, simvastatin. rosuvastatin. atorvastatin). These drugs are designed to lower blood cholesterol. It should be noted that its blood level in patients with a diagnosis of heart ischemia should be two times lower than in a healthy person. Therefore, drugs in this group are immediately used in the treatment of cardiac ischemia.
• Nitrates... These are nitroglycerin and isosorbide mononitrate. They are necessary to stop an attack of angina pectoris. Possessing a vasodilating effect on blood vessels, these drugs make it possible to obtain a positive effect in a short period of time. Nitrates should not be used for hypotension - blood pressure below 100/60. Their main side effects are headaches and low blood pressure.
• Anticoagulants- heparin, which, as it were, “thinns” the blood, which facilitates blood flow and stops the development of existing blood clots, and also prevents new blood clots from developing. The drug can be injected intravenously or under the skin in the abdomen.
• Diuretics (thiazide - hypazide, indapamide; loop - furosemide)... These drugs are necessary to remove excess fluid from the body, thereby reducing the load on the myocardium.

In the news (here) the treatment of angina pectoris with folk remedies!

The following medications are also used: lisinopril. captopril, enalaprin, antiarrhythmic drugs (amiodarone), antibacterial agents and other drugs (mexicor, ethylmethylhydroxypyridine, trimetazidine, mildronate, coronater).

Restriction of physical activity and diet

With physical exertion, the load on the heart muscle increases, as a result of which the demand for oxygen and essential substances of the heart myocardium also increases.

The need does not correspond to the possibility, therefore, manifestations of the disease arise. Therefore, an integral part of the treatment of ischemic heart disease is the limitation of physical activity and its gradual increase during rehabilitation.

Diet for ischemia of the heart also plays an important role. In order to reduce the load on the heart, the patient is limited to drinking water and table salt.

Also, great attention is paid to limiting those products that contribute to the progression of atherosclerosis. Fighting obesity, as one of the main risk factors, is also an integral component.

The following food groups should be limited or discarded:

• animal fats (lard, butter, fatty meats);
• fried and smoked food;
• foods containing a large amount of salt (salted cabbage, fish, etc.).

You should limit the use of high-calorie foods, especially rapidly absorbed carbohydrates. These include chocolate, cakes, sweets, baked goods.

In order to maintain a normal weight, one should monitor the energy and its amount that comes from the food consumed and the actual energy expenditure in the body. At least 300 kilocalories must be ingested daily. An ordinary person who is not engaged in physical work spends about 2000 kilocalories per day.

Surgery

In special cases, surgery is the only chance to save the life of a sick person. The so-called coronary artery bypass grafting is an operation in which the coronary vessels are combined with the external ones. Moreover, the connection is performed in the place where the vessels are not damaged. This operation significantly improves the blood supply to the heart muscle.

Coronary artery bypass grafting is an operation in which the aorta is attached to the coronary artery.

Balloon dilatation of vessels is an operation in which balloons with a special substance are inserted into the coronary vessels. Such a balloon expands the damaged vessel to the required size. It is introduced into the coronary vessel through another large artery using a manipulator.

Endovascular coronary angioplasty is another method of treating cardiac ischemia. Balloon angioplasty and stenting are used. Such an operation is performed under local anesthesia; auxiliary instruments are more often injected into the femoral artery, piercing the skin.

The operation is monitored by an X-ray machine. This is an excellent alternative to direct surgery, especially when the patient has certain contraindications to it.

In the treatment of cardiac ischemia, other methods can be used that do not involve the use of medications. These are quantum therapy, stem cell therapy, hirudotherapy, shock wave therapy, and enhanced external counterpulsation.

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

Home treatment

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

Such treatment involves:

• quitting smoking, including passive smoking;
• refusal from alcohol;
• diet and balanced nutrition, which includes plant foods, lean meat, seafood and fish;
• compulsory consumption of foods rich in magnesium and potassium;
• refusal of fatty, fried, smoked, pickled and too salty foods;
• eating foods that are low in cholesterol;
• normalization of physical activity (walking in the fresh air, swimming, jogging; exercise on a stationary bike);
• gradual hardening of the body, including rubbing and dousing with cool water;
• adequate night sleep.

The degree and type of load should be determined by a specialist doctor. It also requires monitoring and constant consultations with the attending physician. It all depends on the phase of exacerbation and the degree of the disease.

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

Prophylaxis

As preventive measures in preventing the occurrence of heart ischemia, the following should be highlighted:

• you can not overload yourself with work and rest more often;
• get rid of nicotine addiction;
• do not abuse alcohol;
• exclude the use of animal fats;
• restrict foods high in calories;
• 2500 kilocalories per day is the limit;
• the diet should contain foods high in protein: cottage cheese, fish, lean meat, vegetables and fruits;
• engage in moderate physical education, arrange walking.

What's the prognosis?

The prognosis is mostly unfavorable. The disease progresses steadily and is chronic. Treatment only stops the process of the disease and slows down its development.

Timely consultation with a doctor and proper treatment improve the prognosis. A healthy lifestyle and nutritious diet can also help strengthen heart function and improve quality of life.

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Currently, no drugs have yet been developed that can cure such a serious disease as coronary heart disease completely. We are talking about the appointment of special means at the initial stage of the development of the disease in order to prevent its further progression.

Timely diagnosis and active initiation of therapeutic and preventive measures can slow down the further course of pathology, eliminate to some extent negative symptoms, and help prevent complications. Improve the quality of life and increase life expectancy with the help of well-prescribed medications.

This is a number of key points that, in combination, create conditions for the successful treatment of the disease in general, namely, the purpose is shown:

• Special antihypertensive drugs designed to normalize blood pressure.
• Inhibitors (ACE, angiotensin-2 enzyme blockers).
• Beta-blockers.
• Angiotensin-2 receptor blockers.
• Cardiac glycosides.
• Nitrates.
• Agents affecting blood viscosity.
• Diuretics.
• Drugs that regulate blood glucose levels.
• Non-steroidal anti-inflammatory drugs.
• Antihypoxants.
• Vitamin complexes.

Attention! To ensure successful treatment, a number of mandatory factors are required, in addition to the mandatory intake of medications prescribed by a doctor.

Obligatory elimination of all negative factors is a prerequisite for patients with coronary artery disease. Only in this case can we talk about any positive result of therapy.

The patient is obliged to:

• Change your lifestyle.
• Give up bad habits (smoking, alcohol, etc.).
• Provide measures to normalize blood glucose and cholesterol levels.
• Monitor blood pressure readings.
• Fall asleep.
• Avoid stress whenever possible.
• Lead an active lifestyle, etc.

You should take medications prescribed by a cardiologist not from time to time, but constantly. Treatment is carried out exclusively under the supervision of specialists, replacement of drugs and dose adjustment, if necessary, is carried out only by a doctor. Drug use is indicated throughout life from the moment of diagnosis.

If the state of health has deteriorated, a new examination should be carried out and a course of treatment should be taken at a specialized medical cardiology center or the cardiology department of the hospital in the place of residence. It is also recommended to conduct regular courses of therapy in a hospital, regardless of the condition, in order to avoid complications. Good results have been obtained in cardiological sanatoriums, where special programs are provided for such patients.

IHD therapy is always complex. Only in this case is there a high probability of the success of the treatment measures.

Antihypertensive drugs and angiotensin-2 enzyme blockers in the treatment of ischemic heart disease

Fluctuations in blood pressure and an increase in its indicators to significant values ​​have an extremely negative effect on the state of the coronary vessels, as well as on the state of other organs and systems of the body.

The result of increased pressure in relation to ischemic heart disease:

1. Compression of coronary and other vessels.
2. Hypoxia.

Normalization of blood pressure to acceptable levels is a key factor in general therapeutic and preventive measures in the diagnosis of coronary artery disease.

The rate of blood pressure in coronary artery disease

Target level 140/90 mm. rt. Art. and even less (most of the patients).

The optimal level is 130/90 (for patients with diabetes mellitus).

Satisfactory level 130/90 mm. rt. Art. (for patients diagnosed with kidney disease).

Even lower rates are for patients who have a variety of severe comorbidities.

Examples:

APF

ACE belongs to the class of angiotensin-2 enzyme blockers. It is this enzyme that is "guilty" in the mechanism of triggering the increase in blood pressure. In addition, angiotensin-2 has a negative effect on the functional state of the heart, kidneys, and blood vessels.

Facts. Currently, a lot of data have been obtained on the positive effect of ACE on the body of patients with coronary artery disease. The prognosis when taking angiotensin enzyme inhibitors is more favorable, because now these drugs are prescribed very widely (subject to serious contraindications and significant side effects.)

Some drugs that belong to the ACE group:

• Lisinopril
• Perindopril.

Long-term use or excess of dosages in some patients causes a number of side effects, a common complaint. Therefore, ACEs are used only on the recommendation of a cardiologist.

Angiotensin receptor inhibitors

In some cases, this group of drugs (ARBs) has a higher effect, since the therapeutic effect in this case is directed to angiotensin receptors, not angiotensin itself. Receptors are found in the myocardium and other organs.

Angiotensin receptor blockers (ARBs):

• Effectively lowers blood pressure.
• Reduces the risk of overgrowth of the heart (eliminate the risk of hypertrophy).
• They help to reduce the already existing hypertrophy of the heart muscle.
• Can be prescribed to those patients who cannot tolerate angiotensin enzyme blockers.

ARBs have been used as directed by a cardiologist for life.

List of funds:

1. Losartan and its analogues:

1. Valsartan and its analogues:

1. Candesartan and its analogue Atacand
2. Telmisartan, analogue of Mikardis, etc.

The selection of the drug is carried out only by a cardiologist, who takes into account all available factors - the type of disease, the severity of its course, individual manifestations of symptoms, age, concomitant pathologies, etc.

Medicines to improve the functional ability of the heart

This group of drugs is intended for long-term use and is intended to improve the activity of the myocardium.

The products are specifically designed to block adrenal receptors and other stress hormones.

Action:

• Decrease in heart rate.
• Blood pressure normalization.
• General beneficial effect on the heart muscle.

Indications:

• Postinfarction condition.
• Left ventricular dysfunction (with or without concurrent heart failure, provided there are no contraindications).

Courses:

Long-term use.

Short-term appointment.

Contraindications:

• Bronchial asthma.
• Diabetes mellitus (since beta blockers can increase blood sugar).

Examples:

• Anaprilin (obsolete, but still prescribed)
• Metoprolol, Egilok
• Bisoprolol, Concor
• Nebilet

This group of medications is intended for the rapid relief of a painful attack (angina pectoris).

• Nitroglycerin, Nitromint
• Isosorbide dinitrate, Isoket
• Mononitrate, Monocinque.

Application result:

• Expansion of the coronary vessels.
• Reduced blood flow to the heart muscle due to the expansion of the deep veins in which blood accumulates.
• Decrease in heart oxygen demand.
• Analgesic effect due to the combination of the general therapeutic effect.

Attention! With prolonged use of such drugs, addiction sets in, and they cannot have an effect.

AFTER AN INTERRUPTION IN TAKING, THE ACTION RESTORES.

Cardiac glycosides

Appointed if available:

• Atrial fibrillation
• Severe swelling.

Examples:

• Digoxin

Action:

• Strengthening of heart contractions.
• Slowing down of the heart rate.

Peculiarities:

The development of a large number of negative side effects, while co-administration, for example, with diuretics, increases the risk of a side effect and the brightness of its manifestation. Such drugs are prescribed infrequently and only in the case of clear indications.

• no more than 5 mmol / l (total cholesterol),
• not higher than 3 mmol / l (lipoprotein level, "bad" cholesterol with low density);
• not lower than 1.0 mmol / l ("good" high-density cholesterol, lipoproteins).

Attention! An equally important role is played by atherogenic indices and the amount of triglycerides. A whole group of patients, including severe patients with diabetes mellitus, need constant monitoring of these indicators, along with the above.

Examples of some drugs (statin group):

• Atorvastatin

In addition to taking such funds, a mandatory item of the treatment and prophylactic program is the normalization of nutrition. It is not enough to use one, even the most effective diet, without taking medication, and vice versa. Traditional methods are a good addition to the main treatment, but they cannot completely replace it.

Drugs affecting blood viscosity

With increased blood viscosity, the risk of thrombosis in the coronary arteries increases. In addition, viscous blood interferes with the normal blood supply to the myocardium.

Therefore, in the treatment of coronary artery disease, special means are actively used, which are divided into two groups:

• Anticoagulants
• Antiplatelet agents.

It is the most common, effective and available blood thinner and is recommended for patients with CHD for a long time.

Dose:

70 - 150 mg per day. After heart surgery, the dose is often increased.

Contraindications:

• Diseases of the gastrointestinal tract (stomach ulcer)
• Diseases of the hematopoietic system.

This anticoagulant is prescribed for a persistent form of atrial fibrillation.

Action:

• Ensuring the maintenance of INR (blood clotting) indicators.
• Dissolution of blood clots.
• The normal level of INR is 2.0 - 3.0.
• Main side effect:
• The possibility of bleeding.

Reception features:

• after a comprehensive examination
• under the control of laboratory blood tests.

Currently, the blood sugar control criterion is used, which displays the amount of glucose in a patient over the past seven days - this is a determination of the level of glycated hemoglobin. A one-time analysis from case to case cannot give a complete picture of the course of the disease.

Norm:

HbA1c (glycated hemoglobin) no more than 7%.

Stabilization of blood sugar is achieved through non-drug measures:

• applying a special diet
• increased physical activity
• reduction in excess body weight.

In addition, if necessary, medications are prescribed (by an endocrinologist).

Other drugs - diuretics, antihypoxants, nonsteroidal anti-inflammatory drugs

Diuretics (diuretics)

Action:

• Lowering blood pressure (in low dosages).
• In order to remove excess fluid from tissues (high doses).
• With symptoms of congestive heart failure (high doses).

Examples:

• Lasix

Some of the drugs have a sugar-increasing effect, so they are used with caution in the case of diabetes.

Antihypoxants

Action:

Decrease in the oxygen demand of the heart muscle (at the molecular level).

Example of a remedy:

Non-steroidal anti-inflammatory drugs

Until recently, NSAIDs were often used by patients with coronary artery disease. Large-scale studies in America have confirmed the negative effect of these drugs on patients with myocardial infarction. Studies have shown a worsening prognosis for such patients in the case of the use of NSAIDs.

Examples of funds:

• Diclofenac
• Ibuprofen.

1. You should never take any of the most expensive and popular drug that has helped a loved one or a friend well, even if he has the same diagnosis as yours. An illiterate selection of a medicine and its suboptimal dosage will not only not help, but will also harm health.
2. It is categorically impossible to select any medications according to the instructions for them, which are contained in the package. The insert is provided for informational purposes only, but not for self-medication and dose selection. In addition, the doses indicated in the instructions and those recommended by the cardiologist may differ.
3. You should not be guided in the choice of drugs by advertising (TV, media, newspapers, magazines, etc.). This is especially true of various "miracle" drugs that are not distributed through the official pharmacy network. Pharmacies that are authorized to sell medicines must also receive a special license confirming this right. Their activities are regularly monitored by the relevant authorities. Unscrupulous distributors, whose activities cannot be controlled, often promise almost instant healing in such cases and often advocate the complete exclusion of traditional medications that the doctor has prescribed from the course of treatment. This is extremely dangerous for patients suffering from their favorite forms of coronary artery disease.
4. You should not trust the selection of any drugs to a pharmacy worker. Such a specialist has other tasks. Treatment of patients is not within the competence of a pharmacist, even if he has sufficient experience in his field.
5. Only an experienced cardiologist with extensive experience in clinical practice can correctly prescribe a drug, determine the duration of treatment, select the optimal doses, analyze drug compatibility and take into account all the nuances. The doctor selects the treatment only after a complex, serious and rather long-term examination of the body, which includes hardware and laboratory tests. Do not neglect the recommendations of experts and refuse such a study. Coronary heart disease treatment is not an easy and not a quick task.
6. In the case when drug therapy does not give the desired effect, the patient is usually offered a surgical operation. There is no need to give it up. A successful operation in severe coronary artery disease is able to save the patient's life and raise it to a new, higher quality level. Modern cardiac surgery has achieved tangible success, so you should not be afraid of surgical intervention.

Conclusions. Therapy for the diagnosis of coronary heart disease should be carried out throughout life. The same can be said for specialist observation. It is impossible to stop medication treatment on your own, since abrupt withdrawal can cause serious complications, for example, myocardial infarction or cardiac arrest.

We try to provide the most relevant and useful information for you and your health. The materials posted on this page are for informational purposes and are intended for educational purposes. Site visitors should not use them as medical advice. The determination of the diagnosis and the choice of the treatment method remains the exclusive prerogative of your attending physician! We are not responsible for possible negative consequences arising from the use of information posted on the site site

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

Nitrates. The effectiveness of nitrates in relieving angina attacks and in prophylactic administration before exercise is well known. However, with constant intake of nitrates, for example, 3-4 times a day, tolerance to nitrates arises with a decrease or disappearance of the anti-ischemic effect. To prevent the development of tolerance, it is advisable to take a break of at least 10-12 hours during the day, i.e. prescribe nitrates either mainly in the daytime, or only at night (depending on the specific situation), and for constant use, use drugs of other groups.

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

Beta blockers. Beta blockers are the treatment of choice in the treatment of exertional angina. In addition to the antianginal effect, a sign of a sufficient beta-blockade is a decrease in heart rate of less than 60 per minute and the absence of pronounced tachycardia during exercise. With an initial pronounced bradycardia, for example, with a heart rate of less than 50 per minute, beta-blockers with intrinsic sympathomimetic activity (beta-blockers with ICA), for example, pindolol (whiskey), are used.

Calcium antagonists. Calcium antagonists are the treatment of choice for spontaneous ("vasospastic") angina pectoris. For exertional angina, calcium antagonists such as verapamil and diltiazem are almost as effective as beta-blockers. It should be recalled that the use of short-acting forms of nifedipine is currently not recommended. Preference should be given to verapamil, diltiazem and prolonged forms of dihydropyridine calcium antagonists (amlodipine, felodipine).

Prescription of other drugs is justified in case of refractoriness to "standard" therapy, the presence of contraindications to the appointment of one or another group of antianginal drugs or their intolerance. For example, if you have contraindications to beta-blockers and verapamil, you can try using cordarone.

There are reports of the antianginal effect of aminophylline: taking aminophylline reduces the manifestation of ischemia during a load test. The mechanism of the antianginal action of aminophylline is explained by the so-called. "Robin Hood effect" - a decrease in vasodilation of unaffected coronary arteries (antagonism with adenosine) and redistribution of blood flow in favor of ischemic areas of the myocardium (a phenomenon opposite to the "steal phenomenon"). In recent years, evidence has emerged that the addition of drugs with the cytoprotective effect of mildronate or trimetazidia to antianginal therapy can enhance the anti-ischemic effect of antianginal drugs. Moreover, these drugs have their own anti-ischemic effect.

In order to prevent the onset of myocardial infarction and sudden death, all patients are prescribed aspirin at 75-100 mg / day, and if it is intolerant or contraindicated, clopidogrel. Many experts believe that the appointment of statins is also indicated for all patients with coronary artery disease, even with normal cholesterol levels.

Antianginal drugs

A drug	Average daily doses (mg)	Receive frequency
Nitroglycerine	On demand
Nitrosorbide
Trinitrolong
Niroglycerin ointment
Isoket (cardiket) -120
Isoket (kardiket) retard
Isosorbide-5-mononirate (monocinque, efox)
Nitroderm plaster
Molsidomin (korvaton, dilacid)
Beta blockers
Propranolol (obzidan)
Metoprolol (Metocard, Corvitol)
Oxprenolol (trazicor)
Pindolol (whiskey)
Nadolol (korgard)
Atenolol (tenormin)
Bisoprolol (concor)
Carvedilol (dilatrend)
Nebivolol (nebilet)
Calcium antagonists
Verapamil (Isoptin SR)
Nifedipine GITS (osmo-adalat)
Diltiazem (Dilren)
Diltiazem (altiazem PP)
Isradipine (lomir SRO)
Amlodipine (Norvasc)
Additional drugs
Cordaron
Euphyllin
Mildronate (?)
Trimetazidine (?)

Features of the treatment of various options for angina pectoris

Exertional angina

For relatively inactive patients with moderate angina pectoris, especially in old age, it is often sufficient to recommend taking nitroglycerin in cases where the attack does not go away on its own after cessation of the load for 2-3 minutes and / or prophylactic intake of isosorbide dinitrate before exercise, for example, nitrosorbide 10 mg (under the tongue or by mouth) or isosorbide-5-mononitrate 20-40 mg by mouth.

For more severe exertional angina, beta-blockers are added to the treatment. The dose of beta-blockers is selected not only for the antianginal effect, but also for the effect on heart rate. The heart rate should be about 50 per minute.

In the presence of contraindications for beta-blockers or in case of insufficient effectiveness of treatment with beta-blockers, calcium antagonists or long-acting nitrates are used. In addition, amiodarone can be used instead of beta blockers. With angina pectoris III-IV FC, combinations of 2-3 drugs are often used, for example, constant intake of beta-blockers and calcium antagonists and prophylactic intake of prolonged nitrates before exercise.

One of the most common mistakes when prescribing antianginal drugs is their use in insufficient doses. Before replacing or adding a drug, it is necessary to evaluate the effect of each drug at the maximum tolerated dose. Another mistake is the appointment of a constant intake of nitrates. It is advisable to prescribe nitrates only before the planned load, which causes angina pectoris. The constant intake of nitrates is useless or even harmful, because causes a rapid development of tolerance - a progressive decrease or complete disappearance of antianginal action. The effectiveness of drugs is constantly monitored to increase exercise tolerance.

Patients with severe angina pectoris (FCIII-IV), despite drug treatment, are shown coronary angiography to clarify the nature and extent of coronary artery disease and to assess the possibility of surgical treatment - balloon coronary angioplasty or coronary artery bypass grafting.

Features of the treatment of patients with syndrome X. Syndrome X is called exertional angina in patients with normal coronary arteries (the diagnosis is made after coronary angiography). Syndrome X is caused by a decrease in the ability to vasodilate small coronary arteries - "microvascular angina".

Surgical treatment is not possible in patients with syndrome X. Pharmacotherapy for syndrome X is also less effective than for patients with coronary artery stenosis. Refractoriness to nitrates is often noted. The antianginal effect is observed in about half of the patients. Drug treatment is selected by trial and error, first of all, the effectiveness of nitrates and calcium antagonists is evaluated. In patients with a tendency to tachycardia, treatment is started with beta-blockers, and in patients with bradycardia, a positive effect may be observed from the appointment of euphyllin. In addition to antianginal drugs, a-1 blockers such as doxazosin may be effective in Syndrome X. Additionally, drugs such as mildronate or trimetazidine are used. Considering that patients with syndrome X have a very good prognosis, the basis of therapeutic measures is rational psychotherapy, explaining the safety of this disease. Adding imipramine to antianginal preparations (50 mg / day) increases the effectiveness of therapeutic measures.

Spontaneous angina

For the relief of attacks of spontaneous angina pectoris, sublingual nitroglycerin is primarily used. If there is no effect, nifedipine is used (the tablet is chewed).

Calcium antagonists are the drug of choice to prevent recurrent attacks of spontaneous angina pectoris. Calcium antagonists are effective in about 90% of patients. However, it is often necessary to use maximum doses of calcium antagonists or a combination of several drugs of this group at the same time, up to the use of all three subgroups simultaneously: verapamil + diltiazem + nifedipine. If the effect is insufficient, prolonged nitrates are added to the treatment. Within a few months, most patients show marked improvement or complete remission. Especially often, the rapid disappearance of the tendency to spastic reactions and long-term remission are observed in patients with isolated spontaneous angina pectoris, without concomitant exertional angina (in patients with normal or slightly altered coronary arteries).

Beta-blockers can increase the tendency to vasospastic reactions of the coronary arteries. However, if attacks of spontaneous angina appear in a patient with severe exertional angina, calcium antagonists are used in combination with beta-blockers. The use of nibivolol is most advisable. There are reports of a fairly high efficiency of cordaron. In some patients, doxazosin, clonidine, or nicorandil are effective.

Nocturnal angina

There are 3 options: angina pectoris of minimal stress (angina pectoris occurring in the supine position - "angina decubitus" and angina pectoris in dreams with an increase in heart rate and blood pressure), angina pectoris due to circulatory failure and spontaneous angina pectoris. In the first two cases, angina pectoris is the equivalent of paroxysmal nocturnal dyspnea. With all 3 options, the appointment of prolonged-release nitrates at night (prolonged forms of isosorbide dinitrate and mononitrate, nitroderm patch, nitroglycerin ointment) may be effective. With a presumptive diagnosis of low-voltage angina, it is advisable to evaluate the effect of beta-blockers. For spontaneous angina pectoris, calcium antagonists are most effective. In case of circulatory failure, nitrates and ACE inhibitors are prescribed. Consistently evaluating the effectiveness of prescribing various drugs and their combinations, the most appropriate treatment option is selected.

Surgical methods for the treatment of coronary artery disease

The main indication for surgical treatment of coronary artery disease is the persistence of severe angina pectoris (FC III-IV), despite intensive drug treatment (refractory angina pectoris). The very presence of angina pectoris III-IV FC means that pharmacotherapy is not effective enough. The indications and nature of surgical treatment are specified based on the results of coronary angiography, depending on the degree, prevalence and characteristics of coronary artery disease.

There are 2 main methods of surgical treatment for coronary artery disease: balloon coronary angioplasty (CAP) and coronary artery bypass grafting (CABG).

Absolute indications for CABG are the presence of stenosis of the left trunk of the coronary artery or three-vessel lesion, especially if the ejection fraction is reduced. In addition to these two indications, CABG is advisable in patients with two-vessel lesions if there is proximal stenosis of the left anterior descending branch. CABG in patients with stenosis of the left trunk of the coronary artery increases the life expectancy of patients in comparison with drug treatment (survival rate within 5 years after CABG - 90%, with drug treatment - 60%). CABG is somewhat less effective in triple-vessel lesion in combination with left ventricular dysfunction.

Coronary angioplasty is a so-called method. invasive (or interventional) cardiology. During coronary angioplasty, as a rule, stents are inserted into the coronary arteries - metal or plastic endovascular prostheses. With the use of stents, a decrease in the incidence of reocclusions and restenosis of coronary arteries by 20-30% was noted. If there is no restenosis after CAP within 1 year, the prognosis for the next 3-4 years is very good.

Long-term results of CAP have not yet been sufficiently studied. In any case, the symptomatic effect - the disappearance of angina pectoris - is observed in most patients.