In the treatment of Ibs, drugs are recommended. How to prevent ischemic heart disease

Date: 09.04.2019

Treatment of heart ischemia depends on the clinical manifestations of the disease.

The tactics of treatment, the intake of certain drugs and the selection of the mode of physical activity, each patient can be very different.

The treatment of heart ischemia includes the following complex:

therapy without the use of drugs;
medication therapy;
endovascular coronary angioplasty;
treatment with surgery;
other treatments.

Drug treatment of cardiac ischemia involves the patient taking nitroglycerin, which is able to stop angina attacks with a vasodilator effect in a short time.

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

Drugs used in the treatment

Theoapia for ischemic heart disease involves taking the following drugs:

Antiplatelet agents	These include acetylsalicylic acid and clopidogrel. The drugs seem to “liquefy” the blood, helping to improve its fluidity and reducing the ability to adhere platelets and red blood cells to the vessels. And also improve the passage of red blood cells.
Beta blockers	These are 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 amount of oxygen. They have a number of contraindications: chronic lung disease, pulmonary insufficiency, bronchial asthma.
Statins and fibrators	These include lovastatin, fenofibat, simvastatin, rosuvastatin, atorvastatin). These drugs are designed to lower cholesterol in the blood. It should be noted that its blood level in patients with a diagnosis of heart ischemia should be two times lower than that of a healthy person. Therefore, drugs of this group are immediately used in the treatment of ischemia of the heart.
Nitrates	These are nitroglycerin and isosorbide mononitrate. They are necessary for the relief of angina. Having a vasodilating effect on the 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 headache and low blood pressure.
Anticoagulants	Heparin, which “liquefies” the blood, as it were, which facilitates the blood flow and stops the development of existing blood clots, and also prevents new blood clots from developing. The drug can be administered intravenously or under the skin in the abdomen.
Diuretics (thiazide - hypothazide, indapamide; loopback - furosemide)	These drugs are necessary for removing excess fluid from the body, thereby reducing the load on the myocardium.

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

Video

The video describes which drugs can be taken for CHD:

Exercise limitation and diet

During physical exertion, the load on the heart muscle increases, as a result of which the need of the heart for oxygen and necessary substances of the heart also increases.

The need does not match the possibilities, therefore, manifestations of the disease occur. Therefore, an integral part of the treatment of coronary heart disease is limiting physical activity and its gradual build-up during rehabilitation.

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

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

The following product groups should be limited or abandoned:

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

It should limit the use of high-calorie foods, especially fast-absorbing carbohydrates. These include chocolate, cakes, candy, pastry.

In order to maintain a normal weight, you should follow the energy and its quantity, which comes from the food consumed and the actual energy consumption in the body. At least 300 kilocalories daily should be ingested. 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 surgery is an operation in which coronary vessels are combined with 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.

Aortic coronary artery bypass surgery is a surgical procedure where the aorta is attached to the coronary artery.

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

Endovascular coronary angioplasty is another way to treat heart ischemia. Used balloon angioplasty and stenting. Such an operation is performed under local anesthesia, auxiliary instruments are often introduced 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 ischemia of the heart can be used and other methods that do not include the use of drugs. These are quantum therapy, stem cell therapy, hirudotherapy, methods of shock wave therapy, a method of enhanced external counterpulsation.

Home treatment

How can you get rid of heart ischemia and carry out its prevention at home? There are a number of ways that only require patience and the desire of the patient.

These methods predetermine activities that are aimed at improving the quality of life, that is, minimizing negative factors.

This treatment involves:

smoking cessation, including passive smoking;
alcohol rejection;
diet and nutrition, which includes products of plant origin, lean meat, seafood and fish;
mandatory consumption of foods rich in magnesium and potassium;
rejection of fatty, fried, smoked, marinated and too salty foods;
eating low cholesterol foods;
normalization of physical exertion (obligatory walks in the fresh air, swimming, jogging; exercise on a stationary bike);
gradual hardening of the body, including rubbing and pouring cool water;
enough night's sleep.

The degree and type of load should be determined by a specialist doctor. It also requires monitoring and ongoing consultation with your doctor. It all depends on the acute phase and the degree of the disease.

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

Video

Also, you can see what products should be included in your diet to support the cardiovascular system:

Treatment of folk remedies

Herbal medicine plays an important role in the treatment of coronary heart disease, as it helps to increase the effectiveness of pharmacological drugs and improve the quality of life of the patient. Among the plants that best help in curing this disease, hawthorn should be highlighted.

Experts advise to regularly use tea brewed on the basis of its leaves, fruits and flowers. In this case, the fruit is recommended not to grind, and add a few pieces per cup of boiling water.

To improve the blood supply to the heart muscle, you can add medicinal tributary grass, linden leaves with flowers, or meadowsweet flowers.

Enough effective folk remedy for the treatment of coronary heart disease is horseradish. Five grams of the root of this plant should be grated and pour a glass of boiling water. The broth should insist in a thermos for two hours, and then used for inhalation. You can also mix one teaspoon of grated horseradish with one teaspoon of honey and eat it once a day with water. The duration of the course of taking this medication should be a month and a half.

The most famous means of traditional medicine to combat coronary heart disease is garlic. It can be used to prepare a healing tincture, grinding fifty grams of vegetable and pouring a glass of vodka. After three days should begin to use the tincture, diluting eight drops in a teaspoon of cold water.

You need to take the medicine three times a day. Not to mention the importance of medicinal plants such as wood lice, initial letter, horsetail, raspberry leaves, lemon balm, oregano and other herbs that are used to prepare various medical fees.

Prevention

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;
eliminate the use of animal fats;
food high in calories to limit;
2500 calories per day - the limit;
food should be high protein foods: cottage cheese, fish, lean meat, vegetables and fruits;
engage in moderate physical education, arrange walking.

What is the forecast?

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

Timely medical consultation and proper treatment improve the prognosis. A healthy lifestyle and good nutrition also contributes to strengthening heart function and improving the quality of life.

Cardiologist, Functional Diagnosis Doctor

Dr. Zhuravlev for many years helps patients with cardiopathology to get rid of problems in the work of the heart and blood vessels, so the specialist conducts comprehensive therapy for hypertension, ischemia, and arrhythmias.

I will say at once about the abbreviation of IHD used further in the text. This is the abbreviated name for coronary heart disease. This dangerous disease is an acute or chronic heart dysfunction. The disease occurs due to the violation of the patency of blood vessels, which must pass the flow of blood and oxygen directly to the heart muscle.

However, if blood clots (atherosclerotic plaques) form in the cavity of the vessels, they narrow, clog, and the blood flow is disturbed. This narrowing, blockage of the cavity of a vessel thrombus is called ischemia.

In addition to sclerotic plaques, vasospasm can also interrupt blood flow. This happens with a strong, sudden stress, pathological changes in the psycho-emotional state of the patient.

Modern medicine has many ways to treat this pathology, which are widely used with varying degrees of effectiveness. Let's talk today about the signs of CHD modern treatment, the methods of therapy will briefly consider:

Symptoms of ischemia

IHD - usually develops in the second half of life, more often after 50 years. Symptoms usually appear after exercise and appear as follows:

There are signs of angina (pain in the chest).
- There is a feeling of insufficiency of inhaled air, the breath itself is difficult.
- Sudden cessation of blood circulation due to pathologically frequent contractions of the heart muscle (more than 300 contractions per minute), with all the ensuing consequences.

Even familiar with the symptoms of coronary artery disease, you need to know that some patients do not feel any signs of this dangerous disease, even in the presence of a heart attack.

Modern treatment of ischemic disease

The treatment of ischemic heart disease is carried out in several areas:

Drug treatment: Use special drugs to reduce the attacks of the disease, its intensity and frequency. Drugs are designed to strengthen the heart, enhance the patency of the coronary vessels. Typically, drug therapy is used to treat ischemia in the early stages, when drugs are most effective.

Surgery: With the help of a surgical intervention, the treatment of IHD in the acute course is performed, when it is necessary and most effective. Before the operation, the patient’s condition is stabilized, examined, tests are taken, and they are prepared for surgery. The operation is a stenting or coronary artery bypass surgery, which involves the expansion of the lumen of the blood vessels, eliminating the obstacle and stimulating the necessary blood flow to the heart muscle.

Non-surgical treatment of the heart and blood vessels:

Unfortunately, medical therapy is not always effective, and coronary artery bypass surgery (surgery) for some reason can not be performed. Therefore, patients should be aware that modern non-invasive treatment methods have been developed that help fight ischemia without performing a major operation. Here are some methods of non-surgical therapy:

Shock wave therapy. This modern method for the treatment of coronary artery disease involves the use of a shock wave generator, which is specially designed for the clinical and anatomical features of the chest. Shock wave therapy is carried out in several courses. As a result of treatment, angina decreases, the frequency and severity of attacks decrease, and the need for frequent medication is eliminated.

EECP (external counterpulsation). This modern method is intended for the treatment of coronary artery disease, angina, heart failure. Often carried out with insufficient efficacy of drug therapy. EECP is recommended for patients with severe concomitant diseases, such as diabetes. Treatment can be carried out on an outpatient basis.

The result of treatment is a reduction in the class of angina, the frequency and severity of attacks decreases, the need for drugs decreases. After treatment, there are virtually no side effects and complications.

Gravitational. This method involves the use of physiotherapy factor increased gravity. Treatment is indicated for therapeutic, orthopedic and surgical profiles, is the latest medical technique. In the course of treatment, there is an increased muscular load on the lower limbs.

As a result, enhanced blood flow is achieved, the collateral circulation is increased, the process of ischemia development stops, the metabolism improves. This method is very well tolerated by patients, effective and improves the quality of drug treatment.

Stem cells. A new method for the treatment of IHD is the use of the patient’s own stem cells. This treatment is prescribed after a thorough examination, which will confirm the effectiveness of cell treatment in each case.

The need for a particular method of treatment is determined by the attending physician, taking into account the data of the examinations conducted, the severity of the patient’s condition, his age and other indicators.

Remember that CHD is a very dangerous disease, the treatment of which does not require delay. Therefore, in the presence of symptoms, with painful sensations in the chest, immediately consult a cardiologist. Be healthy!

Treatment of coronary artery disease, involves the joint work of the cardiologist and the patient in several ways. First of all, you need to take care of changing your lifestyle. In addition, medication is prescribed, and if necessary, methods of surgical treatment are used.

Changing lifestyle and neutralizing risk factors include a mandatory cessation of smoking, correction of cholesterol levels (with the help of diet or drugs), and weight loss. Patients with coronary artery disease are recommended so-called "Mediterranean diet", which includes vegetables, fruits, light dishes from poultry, fish and seafood.

A very important point in the non-drug treatment of coronary artery disease is the struggle with a sedentary lifestyle by increasing the physical activity of the patient. Of course, a prerequisite for the successful treatment of coronary artery disease is preliminary treatment of hypertension or diabetes, if the development of coronary artery disease occurs against the background of these diseases.

The goals of treating coronary heart disease are defined as improving the quality of life of the patient, that is, reducing the severity of symptoms, preventing the development of such forms of coronary artery disease as myocardial infarction, unstable angina, sudden cardiac death, and increasing the life expectancy of the patient. The initial relief of angina is performed with nitroglycerin, which has a vasodilating effect. The rest of the drug treatment of coronary heart disease prescribed only by a cardiologist, based on an objective picture of the disease. Among the drugs that are used in the treatment of coronary artery disease, drugs can be distinguished to reduce the need for myocardium in oxygen, increase the volume of the coronary bed, etc. However, the main task in the treatment of coronary artery disease - to release the blocked vessels - with the help of medicines is practically not solved (in particular, the sclerotic plaques are almost not destroyed by medicines). In severe cases, surgery is required.

Aspirin has been considered a classic remedy for the treatment of coronary artery disease for many years, many cardiologists even recommend using it prophylactically in small quantities (half / one-fourth pill daily).

The modern level of cardiology has a diverse arsenal of medicines aimed at the treatment of various forms of coronary artery disease. However, only medications can be prescribed by a cardiologist and can only be used under the supervision of a physician.

In more severe cases of coronary artery disease, surgical methods of treatment are used. Coronary artery bypass surgery shows quite good results when the artery blocked by a plaque or thrombus is replaced by an “artificial vessel” that takes over the flow of blood. These operations are almost always performed on an inoperative heart during an artificial circulation, after shunting the patient has to recover for a long time from an extensive operating trauma. The method of shunting has many contraindications, especially in patients with a weakened body, but with a successful operation, the results are usually good.

Endovascular surgery (roentgenosurgery) is currently considered the most promising method for the treatment of coronary artery disease. The term "endovascular" is translated as "inside the vessel." This relatively young area of \u200b\u200bmedicine has already gained strong positions in the treatment of IHD. All interventions are carried out without incisions, through punctures in the skin, under x-ray observation, local anesthesia is sufficient for the operation. All these features are most important for those patients for whom traditional surgical intervention is contraindicated due to concomitant diseases or due to the general weakness of the body. Of the methods of endovascular surgery for ischemic heart disease, balloon angioplasty and stenting are most often used, which allow to restore the patency in ischemic arteries. When balloon angioplasty is used, a special balloon is introduced into the vessel, and then it swells up and “moves” atherosclerotic plaques or blood clots to the sides. After that, a so-called stent is introduced into the artery - a reticular tubular frame made of “medical” stainless steel or alloys of biologically inert metals, capable of independently expanding and preserving the shape given to the vessel.

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

1. Limit physical activity. During exercise, the load on the myocardium increases, and as a result, the need of the myocardium for oxygen and nutrients increases. If myocardial blood supply is impaired, this need is not satisfied, which actually leads to manifestations of IHD. Therefore, the most important component of the treatment of any form of coronary artery disease is limiting physical activity and gradually increasing it during rehabilitation.
2. Diet. With CHD to reduce the load on the myocardium in the diet limit the intake of water and sodium chloride (salt). In addition, given the importance of atherosclerosis in the pathogenesis of coronary artery disease, much attention is paid to the restriction of products 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 product groups should be limited or, if possible, discarded.

· Animal fats (lard, butter, fatty meats)
· Fried and smoked food.
· Products containing a large amount of salt (salted cabbage, salted fish, etc.)
· Limit high-calorie meals, especially fast-absorbing carbohydrates. (chocolate, sweets, cakes, pastry dough).

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

3. Pharmacotherapy in IHD.There are a number of groups of drugs that can be shown for use in some form of CHD. In the US, 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, β-blockers and cholesterol-lowering drugs.

Also, if there is concomitant hypertension, it is necessary to ensure that target blood pressure levels are achieved.

- Antiplatelet agents (A). Antiplatelet agents inhibit platelet aggregation and red blood cells, 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 1 time per day in a dose of 100 mg, with suspected myocardial infarction, a single dose can reach 500 mg.
· Clopidogrel - taken 1 time per day, 1 tablet 75 mg. Reception is required for 9 months after endovascular interventions and CABG.
- V-blockers (B). Due to the effect on in-arenoreceptors, adrenergic blockers reduce the heart rate and, as a result, myocardial oxygen consumption. Independent randomized studies confirm the increase in life expectancy when taking in-adrenoblockers and reducing the frequency of cardiovascular events, including repeated. Currently, it is inappropriate to use the drug atenolol, as according to randomized studies, it does not improve the prognosis. B-adrenergic blockers are contraindicated in case of concomitant pulmonary pathology, bronchial asthma, COPD. The following are the most popular adrenoblockers with proven prognosis enhancement properties in CHD.
· Metoprolol (Betalok Zok, Betalok, Egilok, Metocard, Vazokardin);
· 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 effect on life expectancy, these drugs also reduce the frequency and severity of cardiovascular events. Target cholesterol levels in patients with coronary artery disease should be lower than in individuals 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 significantly reduces the size of an atherosclerotic plaque);

Fibrates. They belong to the class of drugs that increase the anti-atherogenic fraction of HDL, with a decrease which increases the mortality from coronary heart disease. 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 reduce LDL cholesterol and do not have a significant effect on VLDL and PAP. Therefore, a combination of statins and fibrates is required for the most effective treatment of macrovascular complications. With the use of fenofibrate, mortality from coronary heart disease is reduced by 25%. Of the fibrates, only fenofibrate is safely combined with any class of statins (FDA).

· Fenofibrate

Other classes: omega-3 polyunsaturated fatty acids (Omacor). In IBS, they are used to restore the phospholipid layer of the cardiomyocyte membrane. By restoring the structure of the membrane of the cardiomyocyte, Omacor restores the main (vital) functions of the cells of the seed - conductivity and contractility, which were disturbed as a result of myocardial ischemia.

NitratesThere are nitrates for injection.

Preparations of this group are derivatives of glycerol, triglycerides, diglycerides and monoglycerides. The mechanism of action is the effect of the nitro group (NO) on the contractile activity of vascular smooth muscle. Nitrates mainly act on the venous wall, reducing the preload on the myocardium (by expanding the vessels of the venous bed and blood deposition). A side effect of nitrates is a reduction in blood pressure and headaches. Nitrates are not recommended for use with blood pressure below 100/60 mm Hg. Art. In addition, it is now reliably known that taking nitrates does not improve the prognosis of patients with coronary artery disease, that is, it does not lead to an increase in survival, and is currently used as a drug to relieve symptoms of angina pectoris. Intravenous drip of nitroglycerin, can effectively deal with the phenomena of angina, mainly against the background of high numbers of blood pressure.

Nitrates exist in both injectable and tablet form.

· Nitroglycerin;
· Isosorbide mononitrate.

Anticoagulants.Anticoagulants inhibit the appearance of fibrin filaments, they prevent the formation of blood clots, contribute to stopping the growth of already arisen blood clots, 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 dramatically increases the inhibitory effect of the latter on thrombin. As a result, the blood coagulates more slowly).

Heparin is injected under the skin of the abdomen or by intravenous infusion. Myocardial infarction is an indication for the appointment of heparin thrombus, heparin is prescribed at a dose of 12,500 IU, is injected under the skin of the abdomen daily for 5-7 days. In the ICU, heparin is administered to the patient with the help of an infusomat. The instrumental criterion for the appointment of heparin is the presence of depression of the ST segment on the ECG, which indicates an acute process. This symptom is important in terms of differential diagnosis, for example, in cases where the patient has ECG signs of a heart attack that occurred before.

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

Loopback.The drug "Furosemide" in pill form.

Loop diuretics reduce the reabsorption of Na +, K +, Cl - in the thick ascending part of the loop of Henle, thereby reducing the reabsorption (reabsorption) of water. They have a fairly pronounced fast 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). Exists in injectable and tablet form.

Thiazide.Thiazide diuretics are Ca 2+ saving diuretics. By reducing the reabsorption of Na + and Cl - in the thick segment of the ascending part of the loop of Henle and the initial section of the distal tubule of the nephron, thiazide preparations reduce the reabsorption of urine. The systematic use of drugs in this group reduces the risk of cardiovascular complications in the presence of concomitant hypertension.

· Hypothiazide;
· Indapamide.

Angiotensin-converting enzyme inhibitors.Acting on 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 the vasospasm. This ensures that the target blood pressure numbers are maintained. Preparations of this group have a nephro and cardioprotective effect.

· Enalapril;
· Lisinopril;
· Captopril.

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

· Amiodarone refers to the III group of antiarrhythmic drugs, has a complex antiarrhythmic effect. This drug affects the Na + and K + channels of cardiomyocytes, and also blocks the b- and b-adrenoreceptors. Thus, amiodarone has antianginal and antiarrhythmic effects. According to randomized clinical studies, the drug increases the life expectancy of patients who regularly take it. When taking tablets of amiodarone, the clinical effect is observed in approximately 2-3 days. The maximum effect is achieved in 8-12 weeks. This is due to the long half-life of the drug (2-3 months). In this regard, this drug is used in the prevention of arrhythmias and is not a means of emergency care.

Taking into account these properties of the drug, the following scheme of its use is recommended. During the saturation period (first 7–15 days), amiodarone is administered in a daily dose of 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 the maintenance dose of 200 mg per day is reached.

Other groups of drugs.

· Ethyl methyl hydroxypyridine

The drug "Mexidol" in pill form. Metabolic cytoprotector, antioxidant-antihypoxant, which has a complex effect on the key pathogenesis of cardiovascular diseases: anti-atherosclerotic, anti-ischemic, membrane-protective. Theoretically, ethylmethylhydroxypyridine succinate has a significant positive effect, but at present there are no data on its clinical efficacy based on independent randomized, placebo-controlled studies.

· Mexicor;
· Coronator;
· Trimetazidine.
4. The use of antibiotics for IHD.There are results of clinical observations of the comparative effectiveness of two different courses of antibiotics and placebo in patients admitted to hospital with either acute myocardial infarction or 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 justified, and this technique is not included in the standards of treatment of coronary artery disease.
5. Endovascular coronary angioplasty.The use of endovascular (cross-luminal, transluminal) interventions (coronary angioplasty) in various forms of IHD is developing. Such interventions include balloon angioplasty and stenting under the control of coronary angiography. At the same time, instruments are inserted through one of the large arteries (in most cases the femoral artery is used), and the procedure is performed under the control of fluoroscopy. In many cases, such interventions help prevent the development or progression of myocardial infarction and avoid open surgery.

A separate area of \u200b\u200bcardiology, interventional cardiology, deals with this direction in the treatment of IHD.

6. Surgical treatment.

Aorto-coronary bypass surgery is performed.

With certain parameters of coronary heart disease, indications for coronary artery bypass surgery occur — an operation in which myocardial blood supply is improved by connecting the coronary vessels below their lesion with external vessels. The most well-known coronary artery bypass graft (CABG), in which the aorta is connected to the segments of the coronary arteries. To do this, autografts are often used as shunts (usually a large saphenous vein).

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

7. Other non-drug treatments
- Hirudotherapy.Hirudotherapy is a method of treatment based on the use of antiplatelet properties of saliva leeches. This method is an alternative and has not passed clinical trials for compliance with the requirements of evidence-based medicine. Currently in Russia it is used relatively rarely, it is not included in the standards of care for IHD, it is applied, as a rule, at the request of patients. The potential positive effects of this method are the prevention of thrombosis. It should be noted that during treatment according to the approved standards, this task is carried out with the help of heparin prophylaxis.
- Method of shock wave therapy.The impact of low-power shock waves leads to myocardial revascularization.

Extracorporeal focused acoustic wave source allows you to remotely affect the heart, causing "therapeutic angiogenesis" (vessel formation) in the area of \u200b\u200bmyocardial ischemia. The impact of shock wave therapy has a double effect - short-term and long-term. At first, the vessels dilate and blood flow improves. But the most important thing begins later - in the area of \u200b\u200bthe lesion, new vessels arise that provide for already long-term improvement.

Low-intensity shock waves cause 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 effects of angina pectoris. Theoretically, the results of such treatment are a reduction in the functional class of angina pectoris, an increase in exercise tolerance, a decrease in the frequency of seizures, and the need for drugs.

However, it should be noted that at the present time there have not been conducted adequate independent multicenter radiotherapy studies assessing the effectiveness of this technique. Studies cited as evidence of the effectiveness of this technique, as a rule, are made by the companies themselves. Or do not meet the criteria of evidence-based medicine.

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

- The use of stem cells.When using stem cells performing the procedure, it is expected that the introduced potent stem cells differentiate into the missing myocardial cells or adventitia of the vessels. It should be noted that stem cells actually possess this ability, but at the present time the level of modern technologies does not allow differentiation of a poly potent cell into the tissue we need. The cell itself makes the choice of the path of differentiation - and often not the one needed for the treatment of IHD.

This method of treatment is promising, but so far it has not been clinically tested and does not meet the criteria of evidence-based medicine. Years of scientific research are required to provide the effect that patients expect from the introduction of polypotent stem cells.

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

- Quantum therapy of CHD.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.

A serious enough disease and its treatment must be approached with the utmost seriousness. Only a comprehensive appointment of the necessary drugs can bring the desired results. It is also worth remembering that only an experienced, good cardiologist is able to prescribe a suitable therapy. It is not possible to cope with such a task on our own, since it is necessary to take into account not only the individual features of the course of the disease, but also the compatibility of the drugs with each other, so that one of them does not neutralize the effect of the other or, moreover, does not provoke the patient's deterioration. To do this, from each group of drugs is selected the main tool that will neutralize the disease completely.

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

Ischemia is a complex disease that requires a comprehensive approach to treatment. Some pills here will not cope - it is important to change lifestyles, review habits.

Only by observing the necessary regimen in combination with taking the necessary preparations can the desired result be achieved.

It should also be clearly understood that even if the course of treatment brings excellent results and the disease no longer makes itself felt, it still does not mean that you no longer need to take care of your health. In the case of exposure to the body of provoking factors, a relapse in the development of pathology is very great again. At observance of all recommendations of the attending physician there is a high probability that the disease will not return anymore. But at the same time, it is very important to pay attention to taking medications that help maintain the normal heart function.

Selection of therapy

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

causes of CHD;
goal of therapy. Therapy can be supportive (after the main course of treatment and stabilization of the condition), to relieve an acute attack, recovery after surgery, etc .;
accompanying illnesses;
how advanced the disease is, the features of its course, at what stage.

Of course, you need to take into account the individual characteristics of the patient. He may be allergic to any prescribed drugs, have individual intolerance. All this is very important to know the doctor before drawing up a list of recommendations in matters of receiving the necessary drugs.

Additional measures

In addition to taking medications, it is very important to eliminate the effect of absolutely all provoking factors:

lowering blood pressure. and IHD - often not only complement each other, but also separately provoke complications. To prevent this, it is very important to monitor your blood pressure, not allowing not only its smooth and stable increases, but also sharp jumps. It is also important to control your diet. It is obesity that in many ways provokes an increase in blood pressure, so it is worth refusing fatty foods (especially animal fats), as well as quickly digestible carbohydrates;
control of blood cholesterol levels. For this it is necessary to minimize the consumption of sour cream, butter and chicken eggs;
reducing the amount of fluid consumed. Too much fluid intake contributes to the formation of various edemas, which should be avoided in this case. When a large amount of fluid accumulates in the body, blood volume increases, which significantly increases the load on the heart;
smoking cessation and alcohol abuse;
normalization of sugar. For this it is necessary to reduce the consumption of sweets in food;
elimination of other provoking factors, namely the control of your lifestyle. For example, you must have physical activity in the lives of such people, but at the same time physical exertion should be moderate, not cause pain and other unpleasant sensations. Ideal for this swimming or walking in the fresh air. This will simultaneously help to solve several problems: promotes blood thinning, prevents the occurrence of edema, as well as obesity.

Water aerobic exercise

If these simple recommendations are not followed, then even at the completion of a quality and effective treatment course, IHD will soon return again, since the provoking factors in fact will not disappear and will contribute to the resumption of the acute phase of the disease.

Groups of required drugs

As mentioned earlier, an integrated approach to the treatment of IHD is necessary. In the choice of medical drugs should be followed exactly the same tactics to achieve a long-term desired result. Next, we consider the main groups of drugs that are used in the treatment of this disease.

Pressure reducing

High blood pressure has a negative effect on the work of the heart muscle. This is due to the fact that the clamped vessels let oxygen pass worse, which causes oxygen starvation of the heart. Therefore, to control your pressure and keep it normal is the most important task in IHD.

To do this, use the following drugs:

ACE inhibitors

aCE inhibitors. They block the action of substances that increase blood pressure, and also minimize the negative impact of other components on the heart, kidneys, and liver. That is, this medicine contributes precisely to the systematic reduction of pressure;
diuretics. Diuretics do not only reduce blood pressure and minimize the development of hypertension, but also prevent the development of congestion in heart failure. This is also very important if there is a risk of developing brain edema, pulmonary edema. Sometimes in the early stages of hypertension, diuretics are able to stabilize blood pressure on their own without the use of any other drugs. The most important thing is also to minimize salt intake, as it contributes to the retention of body fluids and thereby blocks the action of diuretics.

In ischemic heart disease, such drugs will be required in order to prevent significant increases in blood pressure, as this dramatically and significantly increases the load on the heart muscle, so these drops should be avoided.

Heart work improvement

In this case, the treatment of coronary heart disease includes a variety of drugs that are aimed at solving a variety of problems. Sometimes, at first glance, it may seem that some drugs have absolutely nothing to do with this particular problem, but you should always remember first of all that all the organs in the body are interconnected and therefore problems with one entails problems and other bodies. That is why it is so important in case of serious heart problems to control the health of other organs.

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

Anaprilin

beta blockers. Such drugs block the effect of adrenaline on the heart muscle, or rather, inhibit its production in the body. With serious heart problems, any experiences are destructive and therefore this factor is very important in this case. Also, these drugs can eliminate arrhythmia, help lower blood pressure and reduce heart rate. The drugs are contraindicated in asthma and diabetes. Widely used after myocardial infarction. (Anaprilin, metoprolol);
blood viscosity reducing drugs. The thicker the blood will be in a person - the harder it is for the heart to pump it, and the higher the risk of blood clots. Aspirin is most commonly used for this purpose. It is indicated for use mainly after surgical intervention, as well as for the prevention of blood clots, if there is a predisposition or heredity. In more difficult situations, it is necessary to use drugs to dissolve blood clots (if a blood clot has already formed, but it is not possible to remove it);
drugs to reduce sugar. But at the same time it must be said at once that there is little hope for such drugs if the patient does not follow the basic recommendations, namely diet;
cholesterol reduction. It is this indicator in the blood contributes to the development, as well as hypertension. Ideally, it will be as low as possible in the blood of patients with coronary artery disease. To do this, you must also first of all follow a diet and minimize the consumption of animal fats. But to reduce this figure in one day will not succeed and therefore, if necessary, it is very important to start taking the drugs in a timely manner to stabilize this indicator in the body. Statins are assigned for this purpose. Most often, the doctor prescribes a regular intake of this group of drugs, but here it is important to approach this issue with all seriousness, since the approach should be only comprehensive and nothing else. Intake of drugs will be ineffective without a diet, and a diet without drugs will also not bring the expected results. That is why it is so important to adhere strictly to all the recommendations of a doctor, not only in matters of directly taking medications, but also in relation to nutrition;
contraindications and side effects. The action of drugs is aimed at reducing the frequency of the heart muscle, but at the same time increasing its intensity. Digoxin;
nitrates. Drugs in this group are used directly to relieve an attack. They contribute to the expansion of the coronary vessels and veins to reduce blood flow to the heart, thereby reducing the load on it.
Nitroglycerine
The most commonly used of this group is Nitroglycerin. It reduces the oxygen starvation of the heart (as it reduces its need for oxygen), and also minimizes the pain or eliminates them altogether. The main disadvantage of nitrates is that the body becomes accustomed to them and therefore, with prolonged use, they cease to perform their functions and stop angina attacks. That is why for the long term they are prescribed only for severe forms. Moreover, if even for a short time to cancel their reception, then soon they will again have the desired effect on the patient's body.
Any doctor for ischemic heart disease can only be prescribed by a doctor, since many of these drugs can find a lot of side effects and contraindications, and even with similar symptoms, a great drug for one patient can be destructive for another. The physician should always take into account the individual characteristics of each patient and compile a list of recommendations in accordance with them. Also, before this, it is necessary to undergo a comprehensive examination in order to identify comorbidities and the degree of IHD.

Video

It has a pronounced antianginal effect;

Increases exercise tolerance;

It has a cardioprotective effect;

Improves erectile function in patients with coronary artery disease.

Chronic Ischemic Heart Disease: Treatment News

Published in the journal:

Yu.A. Karpov
Federal State Budgetary Institution Russian Cardiological Research and Production Complex of the Ministry of Health of Russia. 121552, Russia, Moscow, st. 3rd Cherepkovskaya, d. 15a

The main goal of the treatment of chronic ischemic heart disease (CHD) is to reduce the risk of complications, especially myocardial infarction, and mortality (increased life expectancy), while ensuring a good quality of life. Recently, new opportunities have arisen in the treatment of IHD: an increase in the duration of use of dual antiplatelet therapy and a more intensive decrease in the level of low-density lipoprotein cholesterol with the help of combination therapy, new antianginal therapy regimens and some others. The positions of invasive treatment are clarified, including the relationship between endovascular treatment and coronary artery bypass surgery. A modern multicomponent strategy of managing a patient with chronic coronary artery disease allows us to achieve not only an improvement in the quality of life, but also an increase in life expectancy, including without cardiovascular complications.
Keywords: chronic ischemic heart disease, drug treatment, antianginal therapy, invasive treatment.

Chronic ischemic heart disease: treatment news

Yu.A.KarpovH
Russian Cardiological Scientific-Industrial Complex 121552, Russian Federation, Moscow, 3-ia Cherepkovskaia, d. 15a

Ischemic heart disease (IHD) is one of the most important factors that can be taken to reduce life expectancy. IHD have been worked out for a long period of time. The characteristics of the invasive treatment, including the correlation between the endovascular treatment and the coronary artery bypass graft surgery, have been outlined. IHD makes it possible to improve the quality of life, but also to increase life expectancy, without cardiovascular complications.
Key words: chronic ischemic heart disease, drug therapy, antianginal therapy, invasive treatment. [email protected]

In the scheme of drug therapy in accordance with the recommendations for the management of patients with stable coronary artery disease include drugs with a proven positive effect on the prognosis of the disease (Table 1), which are required for the appointment, if there are no direct contraindications to their reception, as well as a large group of antianginal or anti-ischemic drugs.

Prevention of coronary artery disease is accomplished by prescribing antiplatelet agents (acetylsalicylic acid - ASA or clopidogrel), statins (it is important to achieve the target level of low density lipoprotein cholesterol - LDL cholesterol), drugs that block the activity of the renin-angiotensin system. There is evidence of the effectiveness of angiotensin-converting enzyme inhibitors (ACE inhibitors), perindopril and ramipril, and, if they are intolerant, angiotensin receptor blockers. The most pronounced protective effects of an ACE inhibitor in patients with a low left ventricular ejection fraction (LVF), who have had myocardial infarction, diabetes mellitus (DM), and arterial hypertension (AH), however, in patients with IHD without these conditions, one can expect a reduction in cardiovascular risk . Also in the IHD treatment regimen there were ß-blockers (ß-LB), which were recommended for all patients after myocardial infarction.

What changes have occurred or additional features have appeared, the use of which in everyday clinical practice improves the results of treatment of patients with coronary artery disease?

Drugs that improve the prognosis of chronic ischemic heart disease

Antiplatelet therapy. In most patients with stable coronary artery disease, preference is still given to administering ASA in the dose range from 75 to 150 mg / day, which is associated with a favorable ratio of benefits and risks, as well as low cost of treatment. Clopidogrel is considered as a 2nd-line drug, administered at a dose of 75 mg 1 time per day for ASA intolerance or as an alternative to ASA in patients with widespread atherosclerotic lesions.

Combined or dual anti-platelet therapy (DAT), including ASA and a second antiplatelet agent (ticagrelor or clopidogrel), is the standard of treatment for patients who have experienced acute coronary syndrome -OX (depending on the management strategy), as well as patients with stable coronary artery disease undergoing percutaneous Coronary interventions - PCI (ASK with clopidogrel). The duration of treatment in these cases, depending on the type of implantable stent, did not exceed 1 year after the event. Recently, the efficacy and safety of DAN in patients after 1 year or more of myocardial infarction have been actively studied. After completing several studies, especially the PEGASUS-TIMI 54 study, it became apparent that in patients after suffering myocardial infarction after 1 year, it is possible to consider the possibility of a longer prescription of DAT, especially in cases of high risk of ischemic complications and low risk of bleeding, which was noted in new European recommendations for the treatment of patients with myocardial infarction without ST elevation. Recently, a new indication for ticagrelor has been recorded.

As for patients with chronic coronary artery disease, according to the American guidelines for the management of these patients, DAT can be considered in cases where there is a high likelihood of ischemic complications.

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

Recently registered (USA and European Union) a new class of lipid-lowering drugs - PCSK9 monoclonal antibodies-inhibitors or subtilisin-kexin type 9 pro-protein convertase (PSKT9) when subcutaneously reduced LDL cholesterol by 40-60% every 2–4 weeks, including including statins, are well tolerated. Already, these drugs (registration of drugs alirocumab and evolocumab in Russia is planned for 2016) can significantly increase the effectiveness of therapy for patients with familial form of hypercholesterolemia, as well as with intolerance to statins. In the future, with a favorable completion of a whole series of clinical studies that examine the efficacy and safety of PSCT9 inhibitors with long-term use, these drugs can be used in the treatment of patients with coronary artery disease with statins to overcome the "residual" risk.

ß-ab. As already noted, ß-AB was recommended for all patients after myocardial infarction with no limitation on the duration of use, regardless of the presence of angina and other indications for their use, as evidence of the improved prognosis in this cohort of patients was obtained earlier. However, many experts noted that the prescription of ß-AB after 3 years or more after patients with myocardial infarction without angina and heart failure has no evidence of improved prognosis. The fact is that there were no studies with a duration of more than 2–3 years to assess the effect of P-AB on the prognosis after MI. Recently, in the American recommendations for the diagnosis and treatment of stable coronary artery disease, it was first noted that if 3 years after MI there is no angina, chronic heart failure with reduced LV EF, AH, then ß-AB therapy can be terminated. Thus, it is indicated that the ß-AB therapy is not necessary in the absence of angina and other indications for prescribing drugs of this class.

Antianginal (antiischemic) therapy

Therapy aimed at eliminating ischemic manifestations of angina pectoris and / or silent myocardial ischemia includes ß-AB, calcium channel blockers (CCBs), long-acting nitrates, inhibitor if-channels sinus node cells (ivabradine), cytoprotective agents (trimetazidine), an inhibitor of late sodium current (ranolazine) and activator of potassium channels (nicorandil). All of these drugs have an antianginal (anti-ischemic) effect, which has been proven in controlled clinical trials.

ß-ab. For the treatment of angina, β-AB is prescribed in a minimum dose, which, if necessary, is gradually increased until complete control of strokes or the maximum dose is achieved. It is believed that the maximum reduction in myocardial oxygen demand and the increase in coronary blood flow are achieved with a heart rate (HR) of 50-60 beats / min. With a lack of effectiveness, as well as the inability to use the maximum dose of β-AB due to undesirable manifestations, it is advisable to combine them with calcium antagonists - AK (long-acting dihydropyridine derivatives) or ivabradine. In the event of adverse events, it may be necessary to reduce the dose of ß-AB or even cancel them. In these cases, you should consider the appointment of other rhythm-reducing drugs - verapamil or ivabradine. The latter, in contrast to verapamil, can join ß-AB to improve heart rate control and increase anti-ischemic efficacy. If necessary, nicorandil can be attached to ß-AB. In patients with stable angina in combination with diabetes, ranolazine or trimetazidine can be used.

Table 1. Drug treatment of chronic coronary artery disease

BKK

Nitrates and Nitrate-Like Agents. A variety of dosage forms allows the use of nitrates in patients with different severity of the disease, both for the relief and prevention of strokes. Nitrates can be used in combination with other antianginal drugs. Reduced sensitivity to nitrates often develops with long-term use of long-acting drugs or transdermal dosage forms. For the prevention of tolerance to nitrates and its elimination, the intermittent use of nitrates during the day is recommended; taking nitrates of average duration of action - 2 times a day, prolonged action -1 times a day; alternative therapy with molsidomine.

Molsidomine, which is close to nitrates by the mechanism of antianginal action, is prescribed for intolerance to nitrates. It is usually prescribed to patients with contraindications to the use of nitrates (with glaucoma), with poor tolerance (severe headache) of nitrates or tolerance to them.

Sinus node inhibitor ivabradine. The basis of the antianginal action of ivabradine is the selective reduction of heart rate by inhibiting the transmembrane ionic current If in cells of the sinus node. In contrast to ß-AB, ivabradine reduces only heart rate, does not affect contractility, conductivity and automatism of the myocardium, as well as blood pressure (BP). The drug is recommended for the treatment of stenocardia in patients with sinus rhythm with contraindications / intolerance to receiving ß-AB or together with ß-AB with their insufficient antianginal effect. It was shown that the addition of the drug to β-AB in patients with coronary artery disease with reduced LV EF and HR\u003e 70 beats / min improves the prognosis of the disease. The drug is not recommended to appoint simultaneously with the CCU.

Nicorarandil. The antianginal and anti-ischemic drug nicorandil simultaneously has the properties of organic nitrates and activates adenosine triphosphate-dependent potassium channels. Nicorandil therapy effectively reduces myocardial ischemia — it provides simultaneous reduction of LV post-and preload with minimal effect on hemodynamics and does not have many of the drawbacks typical of standard anti-ischemic drugs. Opening the adenosine triphosphate-dependent potassium channels of the mitochondria, nicorandil completely reproduces the protective effect of ischemic preconditioning: it contributes to energy saving in the heart muscle and prevents irreversible cellular changes in ischemia and reperfusion.

A single dose of nicorandil (10 or 20 mg) taken 2 hours before intracutaneous coronary intervention in patients with ACS has been shown to reduce the incidence of troponin I elevation, as well as the frequency of troponin increases by 3 and 5 times compared with the upper limit of normal compared to the control group. It is also proven that nicorandil is able to reduce the incidence of arrhythmias, platelet aggregation, stabilize the coronary plaque, help reduce the severity of free radical oxidation, normalize endothelial function and sympathetic nervous activity in the heart.

Nicorandil does not cause the development of tolerance, does not affect blood pressure, heart rate, conductivity and myocardial contractility, lipid metabolism and glucose metabolism. Recommended for the treatment of patients with microvascular angina (with the ineffectiveness of ß-AB and AK). The drug can also be used to relieve strokes.

In relation to other antianginal drugs there are no data on the effect on the prognosis in patients with stable coronary artery disease. The exception was nicorandil, which in a randomized, double-blind, placebo-controlled study of YNA (Impact Of Nicorandil in А ^ т; Great Britain, n \u003d 5126, mean observation period of 1.6 years) significantly reduced the risk of death from IHD, nonfatal MI by 17% and unplanned hospitalization due to heart pain (p \u003d 0.014) and reduced the risk of ACS by 21% (p \u003d 0.028). Moreover, the maximum decrease in the absolute risk of undesirable events was observed in patients with the highest baseline risk.

In a multicenter prospective observational study in parallel JCAD groups (Japanese Coronary AH: Egu Disease; Japan, n \u003d 5116, mean follow-up period of 2.7 years), the effect of nicorandil on long-term outcomes in patients with coronary artery disease was studied. The frequency of the primary endpoint (death from any causes) in the nicorandil group was 35% lower compared to the control group (p \u003d 0.0008). Also in the nicoradil group, there was a significant decrease in the frequency of additional end points: cardiac death (-56%), fatal myocardial infarction (-56%), cerebrovascular and vascular death (-71%), congestive heart failure (-33%), community-acquired circulatory arrest and respiration (-64%).

In another observational study, the OASK (Osaka Acute Coronary Insufficiency Study; Japan, n \u003d 1846, median follow-up period of 709 days) for patients with acute MI undergoing emergency PCI, nicorandil, administered orally since discharge, reduced the risk of death from any causes by 50, 5% (p \u003d 0.0393) regardless of the outcome of PCI. However, nicorandil is used in clinical practice only for the treatment of angina pectoris.

Randomized clinical studies using nicorandil of domestic production revealed additional clinical effects in patients with stable coronary artery disease in relation to isosorbid-5-mono-nitrate: improved erectile function and increased increase in the diameter of the cavernous arteries in men, increased cerebral blood flow, which is especially important for elderly patients with cerebrovascular insufficiency. The addition of nicorandil to standard therapy of stable angina pectoris contributed to a significant decrease in the concentration of highly sensitive C-reactive protein (p \u003d 0.003) and fibrinogen level (p \u003d 0.042) while receiving rosuvastatin, which confirms the positive effect of nicorandil on the reduction of oxidative damage and systemic inflammation. The use of nicorandil in patients with stable angina of the III functional class, complicated by heart failure with low LV EF, allowed not only to get a more pronounced antianginal effect, but also to improve the systolic function of the heart and reduce LV remodeling.

Ranolazine selectively inhibits late sodium channels that prevent overloading with intracellular calcium, a negative factor in myocardial ischemia. Ranolazin reduces contractility and myocardial stiffness, improves myocardial perfusion, reduces myocardial oxygen demand, and has no effect on heart rate and blood pressure. Usually prescribed in combination therapy with insufficient anti-angina efficacy of essential drugs.

In a recently completed study, the effect of ranolazine on the course of coronary artery disease in patients after incomplete myocardial revascularization using PCI with stenting was studied. Previously, it was shown that 80% of patients after PCI have incomplete myocardial revascularization, which is subsequently associated with higher mortality and repeated hospitalizations with revascularization. The RIVER-PCI study included 2,619 patients between November 2011 and May 2013 in 245 centers in Israel, the United States, Europe and Russia, which were randomized to receive ranolazine 1000 mg 2 times a day (n \u003d 1332) or placebo (n \u003d 1297). Three-vascular lesion was present in 44% of patients, 33% had chronic complete occlusion, and 14% had previously undergone coronary artery bypass surgery (CABG). All had incomplete revascularization, which was defined as the presence of one or more lesions with 50% or more stenosis in the coronary artery (CA) 2 mm in diameter or more.

The mean follow-up period was 643 days, during which 26.2% of patients of the ranolazine group and 28.3% of the placebo group experienced events of the combined primary endpoint (revascularization or hospitalization without myocardial ischemia or revascularization without revascularization). The difference was not significant (risk ratio, 0.95). However, the researchers noted a very high incidence of cardiovascular events in patients with incomplete revascularization. In almost 1/2 of the cases of re-performed revascularization associated with the development of ischemia, PCI was performed on stenoses that were previously left untreated. There were no significant differences in the frequency of development of individual events of the primary or secondary end points: revascularization associated with ischemia (15.3% versus 15.5%, respectively, in the ranolazine and placebo groups); hospitalization associated with ischemia without revascularization (15.3% vs. 17.9%); cardiovascular death (1.6% versus 1.6%); sudden cardiac death (0.5% versus 0.9%) or MI (8.4% versus 9.0%). In the ranolazine group, transient ischemic attacks were more frequent than in the placebo group (1.0% vs. 0.2%; hazard ratio 4.36; p \u003d 0.02) and significantly more patients completed the study prematurely for all reasons (40.0 % versus 35.7%, p \u003d 0.006); tab. 2

One of the possible reasons for the failure of the project, the researchers believe the lack of objective evidence of the resumption of ischemia after PCI as a criterion for inclusion in the study. Thus, the use of ranolazine in patients with chronic coronary artery disease after incomplete revascularization does not affect the prognosis of the disease.

Table 2. RIVER-PCI study: the effect of ranolazine on the course of coronary artery disease in patients with incomplete revascularization after PCI

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

After the publication of the main result of the RIVER-PCI study, a new analysis of QoL assessment was conducted using the QoL (Quality of Life) questionnaire. Analysis of 2389 study participants showed that although in both groups there was a significant improvement in QOL on the scale of the Seattle questionnaire for 1 month and 1 year after index PCI, no significant differences between the ranolazine and placebo groups were found. However, in patients with diabetes and in the group with more severe angina, the baseline had a significant improvement on this questionnaire 6 months after the intervention, which was leveled by 12 months.

Trimetazidine. The drug is an anti-ischemic metabolic modulator, improves the metabolism and energy supply of the myocardium, reduces myocardial hypoxia, without affecting the hemodynamic parameters. May be prescribed with any other antianginal drugs. Recently, restrictions have been made on the appointment of the drug for movement disorders (Parkinson's disease, essential tremor, muscle rigidity and restless legs syndrome). Currently, the efficacy of the drug in reducing the risk of cardiovascular events in more than 7 thousand patients after PCI with stenting in an international randomized placebo-controlled study (AT-PCI) is being studied.

Features of medical treatment of vasospastic angina

ß-AB for angiographically intact spacecraft with vasospastic angina pectoris are not recommended. The best results for the prevention of ischemia in patients with vasospastic angina pectoris show BPC. However, there is almost no data on the effect of such therapy on the prognosis of vasospastic angina pectoris. Recently, researchers from the Japanese Association of Coronary Spasm conducted a multicenter study that included 1429 patients (mean age 66 years; men / women 1090/339) with vasospastic angina pectoris (the diagnosis was made by the decision of the participating doctors). Over 90% of patients received BPC therapy; 695 (49%) took different nitrates, such as nitroglycerin, isosorbide mononitrate and dinitrate (551 patients) and nicorandil (306 patients). The primary end point was the sum of cardiac events (cardiovascular death, nonfatal MI, hospitalization with unstable angina or heart failure, successful reanimation).

During the study (an average of 32 months), events of the primary endpoint were observed in 5.9% of patients. According to the analysis of the same matched pairs, the overall frequency of cardiac events was the same in patients who received and did not receive long-term nitrate therapy (11% vs. 8%, respectively, for 5 years; risk ratio 1.28; 95% confidence interval - DI 0.72 -2.28). Nicorandil monotherapy was associated with a neutral effect on the prognosis of vasospastic angina pectoris (hazard ratio 0.8; 95% CI 0.28-2.27). However, according to multivariate analysis (Cox model), the simultaneous use of different nitrates with nicorandil may increase the risk of cardiac events (hazard ratio 2.14; 95% CI 1.02-4.47; p \u003d 0.044), especially when simultaneous use of nitroglycerin and nicorandil. It was concluded that long-term use of nitrates in combination with BPC did not improve the prognosis of patients with vasospastic angina.

In cases where the spasm of CA takes place against the background of stenosing atherosclerosis, small doses of ß-AB can be administered in combination with dihydropyridine AK. The prognostic effect of ASA, statins, ACE inhibitors in vasospastic angina pectoris in the presence of angiographically intact spacecraft has not been studied.

Features of the medical treatment of microvascular angina

Currently, the administration of statins and antiplatelet agents is also recommended for the treatment of this form of CHD. For the prevention of attacks, ß-AB is primarily prescribed, and with insufficient efficacy, AK and long-acting nitrates are used. In cases of persistent angina, ACE inhibitors and nicorandil are prescribed. Previously published clinical observations on the effectiveness of nicoradil in patients with this form of angina.

The recently completed RWISE study involved 142 patients (96% women; mean age 55 years) with microvascular angina. In addition to the symptoms associated with myocardial ischemia, everyone did not have obstructive lesions of the CA (less than 50% stenosis) and reduced coronary reserve (less than 2.5) when tested with acetylcholine. In this placebo-controlled study, ranolazine was not effective in reducing the number of strokes of exertional angina or improving myocardial perfusion (p \u003d 0.81). However, in the ranolazine group, there was a decrease in the symptoms of depression (p \u003d 0.009). Thus, in patients with microvascular angina, the effect of the drug on the reserve index of myocardial perfusion was not detected.

Myocardial revascularization in chronic ischemic heart disease

When discussing the issue of myocardial revascularization with stable angina (balloon angioplasty with stenting of coronary artery or CABG), the following circumstances are taken into account:

The effectiveness of antianginal therapy. If, after prescribing a patient, including combination therapy, in optimal doses, angina pectoris persists with an unacceptable frequency for this particular patient, it is necessary to consider the issue of revascularization.
The results of stress tests. The results of any stress test can reveal criteria for a high risk of complications, which indicate an unfavorable long-term prognosis.
Risk of interference. They take into account the anatomical features of spacecraft lesions, the clinical characteristics of the patient, and the operational experience of this institution. As a rule, they refrain from invasive procedures in cases where the perceived risk of death during it is greater than the risk of death of a particular patient for 1 year.
The question of invasive treatment should be discussed in detail with the patient, and the decision should be made collectively with the participation of the attending physician, surgeon and invasive cardiologist. After a successful invasive therapy, you must continue to take medication.

The choice of myocardial revascularization method

It should be recalled that previous studies, in particular the COURAGE study, did not establish advantages in improving the long-term prognosis when comparing two patient management strategies with stable coronary artery disease - only optimal drug therapy (OMT) or PCI with implantation of mostly uncoated metal stents + OMT. The results of a nearly 12-year follow-up of a part of patients who had previously participated in the COURAGE study were recently published. It turned out that with longer periods of observation, the number of deaths from all causes in both groups did not statistically differ (Table 3).

These and other data suggest that PCI is shown, as a rule, only in case of ineffective antianginal treatment in order to improve QL of patients with stable coronary artery disease, since this invasive therapy method does not affect the risk of cardiovascular events and death.

Table 3. COURAGE study: the effect of PCI on long-term survival in patients with stable coronary artery disease

Survival information was available for 1211 patients or 53% of the original population.
with an average observation period of 11.9 years. A total of 561 patients died during follow-up, of which
180 - during the first study and 381 - during the extended observation period

Successful shunting of spacecraft improves not only QOL, but also in a number of clinical situations - the prognosis of the disease, reducing the risk of non-fatal MI and death from cardiovascular complications. This applies to patients who have stenosis of more than 50% of the main trunk of the left CA; stenosis of the proximal segments of all three major spacecraft; coronary atherosclerosis of other localization involving the proximal anterior descending and circumflex arteries; multiple occlusions of spacecraft; diffuse distal hemodynamically significant stenosis of the CA. Reduction of LV systolic function (LV EF<45%) является дополнительным фактором в пользу выбора шунтирования как способа реваскуляризации миокарда.

In recent years, several randomized studies have been conducted, which compared the results of CS and PCI in patients with multivessel SC. In the SYNTAX, FREEDOM and ARTSII studies, only stents coated with first-generation drugs were used. The incidence of stent thrombosis was from 5 to 10% over 5 years. Since stent thrombosis is accompanied, as a rule, by an unfavorable outcome, this determined the worst prognosis in the group of stented patients compared with the operated ones. With the use of second generation drug-eluting stents, the incidence of stent thrombosis and, importantly, stress the need for repeated revascularization less. In a recent meta-analysis, in which stenting and CSH were compared in the treatment of patients with diabetes with a multi-vascular lesion, it was shown that the frequency of repeated revascularization is constantly decreasing when PCI changes from the highest when ballooning to the first generation with the first generation drug-eluting stents case of implantation of drug-eluting stents of the II generation. Currently, two large studies are being conducted (EXCEL and NOBLE), which study in modern conditions the effectiveness of treating patients with unprotected damage to the main trunk of the left CA and complex defeat of CA with a low or intermediate SYNTAX index using a new generation of drug-coated stents. The first results of these studies are expected in 2016.

Conclusion

IHD is a common cardiovascular disease and is the main cause of cardiovascular mortality in Russia. A treatment regimen with antiplatelet medication, statins, renin-angiotensin-aldosterone system blockers and antianginal drugs should be used in all patients with a diagnosis of stable coronary artery disease with stenocardia.

In the event of an onset of strokes, despite the treatment being carried out and in certain clinical situations, invasive treatment is carried out, in the choice of which (stenting or CS) the attending physician, coronary surgeon and invasive cardiologist take part in taking the patient's opinion into account.

A modern multicomponent strategy for managing a patient with chronic coronary artery disease can not only improve QOL, but also increase life expectancy, including without cardiovascular complications.

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