The Coronary Heart Disease (CHD) – the organic and functional damage of a myocardium caused by a shortcoming or the termination of blood supply warm a muscle (ischemia). IBS can be shown sharp (a myocardial infarction, cardiac arrest) and chronic (stenocardia, a postinfarction cardiosclerosis, heart failure) by states. Clinical signs of IBS are defined by a concrete form of a disease. IBS is the reason of sudden death, most widespread in the world, including persons of working-age.
Coronary heart disease
Coronary heart disease is the most serious problem of modern cardiology and medicine in general. In Russia about 700 thousand death caused by the IBS various forms are annually fixed, in the world mortality from IBS makes about 70%. Coronary heart disease more affects men of active age (from 55 to 64 years), resulting in disability or sudden death.
The imbalance between the need of a cardiac muscle for blood supply and the actual coronary blood-groove is the cornerstone of development of IBS. This imbalance can develop in connection with sharply increased need of a myocardium for blood supply, but its insufficient implementation, or at usual requirement, but sharp decrease in coronary blood circulation. Deficiency of blood supply of a myocardium is especially expressed in cases when the coronary blood-groove is lowered, and the need of a cardiac muscle for blood inflow sharply increases. Insufficient blood supply of tissues of heart, their oxygen starvation is shown by various forms of coronary heart disease. Sharply developing and chronically proceeding conditions of ischemia of a myocardium which are followed by the subsequent its changes enter into the IBS group: dystrophy, necrosis, sclerosis. These states in cardiology are considered, including, and as independent nosological units.
Reasons and risk factors of coronary heart disease
The vast majority (97-98%) of clinical cases of IBS is caused by atherosclerosis of coronary arteries of various degree of expressiveness: from insignificant narrowing of a gleam an atherosclerotic plaque to full vascular occlusion. At a 75% koronarostenoz of a cell of a cardiac muscle react to a lack of oxygen, and at patients tension stenocardia develops.
As other reasons causing IBS serve the thrombembolia or a spasm of coronal arteries developing usually against the background of already available atherosclerotic defeat. The cardiospasm aggravates obstruction of coronary vessels and causes displays of coronary heart disease.
Treat the factors promoting emergence of IBS:
Promotes development of atherosclerosis and increases risk of coronary heart disease by 2-5 times. In respect of risk of IBS giperlipidemiya of the types IIA, IIB, III, IV, and also reduction of maintenance of alpha lipoproteins are the most dangerous.
The arterial hypertension increases probability of development of IBS by 2-6 times. At patients with systolic HELL = 180 mm of mercury. above coronary heart disease meets to 8 times more often than at hypotensives and people with the normal level of arterial pressure.
According to various data, smoking of cigarettes increases incidence of IBS by 1,5-6 times. The lethality from coronary heart disease among men of 35-64 years smoking 20-30 cigarettes daily is twice higher, than among non-smoking the same age category.
- hypodynamia and obesity
Physically low-active people risk to get sick with IBS 3 times bigger, than the persons leading active lifestyle. At a hypodynamia combination to excess body weight this risk increases many times.
- violation of tolerance to carbohydrates
At diabetes, including latent, the risk of incidence of coronary heart disease increases by 2-4 times.
It is necessary to refer also burdened heredity, a male and advanced age of patients to the factors creating threat of development of IBS. At a combination of several contributing factors, risk degree significantly increases in development of coronary heart disease.
The reasons and speed of development of ischemia, its duration and expressiveness, initial condition of cardiovascular system of an individual define emergence of this or that form of coronary heart disease.
Classification of coronary heart disease
As working classification, under the WHO recommendation (1979) and VKNTs USSR Academy of Medical Sciences (1984), cardiologists-clinical physicians use the following systematization of the IBS forms:
1. Sudden coronary death (or primary cardiac arrest) the - suddenly developed, unforeseen state which cornerstone presumably electric instability of a myocardium is. Sudden coronary death is understood as the instant or come no later than 6 hours after heart attack death in the presence of witnesses. Allocate sudden coronary death with successful resuscitation and with a lethal outcome.
- stenocardia of tension (loading):
- stable (with definition of a functional class I, II, III or IV);
- unstable: for the first time arisen, progressing, early postoperative or postinfarction stenocardia;
- spontaneous stenocardia (Xing. special, alternative, vazospastichesky, Printsmetal's stenocardia)
3. Bezbolevy form of ischemia of a myocardium.
- krupnoochagovy (transmuralny, Q-heart attack);
- melkoochagovy (not a Q-heart attack);
6. Violations of warm conductivity and rhythm (form).
7. Heart failure (form and stages).
In cardiology there is a concept of the "sharp coronary syndrome" uniting various forms of coronary heart disease: unstable stenocardia, a myocardial infarction (with a Q-tooth and without Q-tooth). Sometimes include in the same group also the sudden coronary death caused by IBS.
Symptoms of coronary heart disease
Clinical manifestations of IBS are defined by a concrete form of a disease (look a myocardial infarction, stenocardia). In general coronary heart disease has a wavy current: the periods of steadily normal health alternate with episodes of an exacerbation of ischemia. About 1/3 patients, especially with bezbolevy ischemia of a myocardium, do not feel existence of IBS at all. Progressing of coronary heart disease can slowly develop, decades; at the same time disease forms, and so, and symptoms can change.
The zagrudinny pains connected with physical activities or stresses, back, hand, lower jaw pains belong to the general manifestations of IBS; short wind, the strengthened heartbeat or feeling of interruptions; weakness, nausea, dizziness, turbidity of consciousness and faints, excessive perspiration. Quite often IBS comes to light already at a stage of development of the chronic heart failure at emergence of hypostases on the lower extremities expressed to the short wind forcing to accept the patient the compelled sitting position.
The listed symptoms of coronary heart disease usually do not meet at the same time, at a certain form of a disease prevalence of these or those displays of ischemia is observed.
As harbingers of primary cardiac arrest at coronary heart disease the arising feelings of discomfort behind a breast, fear of death, psychoemotional lability can serve pristupoobrazno. At sudden coronary death the patient faints, there is respiratory standstill, there is no pulse on the main arteries (femoral, sleepy), tones of heart are not listened, pupils extend, integuments become a pale grayish shade. Cases of primary cardiac arrest make up to 60% of lethal outcomes of IBS, mainly at a pre-hospital stage.
Complications of coronary heart disease
Haemo dynamic violations in a cardiac muscle and its ischemic damages cause the numerous morfo-functional changes defining forms and the forecast of IBS. The following mechanisms of a decompensation are result of ischemia of a myocardium:
- insufficiency of power metabolism of cells of a myocardium – kardiomiotsit;
- "deafened" and "sleeping" (or giberniruyushchiya) a myocardium – forms of violation of a sokratimost of the left ventricle at patients about IBS having passing character;
- development of a diffusion atherosclerotic and focal postinfarction cardiosclerosis – reduction of quantity of the functioning kardiomiotsit and development on their place of connecting fabric;
- violation of systolic and diastolic functions of a myocardium;
- disorder of functions of excitability, conductivity, automatism and sokratimost of a myocardium.
The listed morfo-functional changes of a myocardium at IBS lead to development of permanent decrease in coronary blood circulation, i.e. heart failure.
Diagnosis of coronary heart disease
Diagnostics of IBS is performed by cardiologists in the conditions of a cardiological hospital or a clinic with use of specific tool techniques. At poll of the patient complaints and existence of symptoms, characteristic of coronary heart disease, become clear. At survey existence of hypostases, cyanosis of integuments, noise in heart, violations of a rhythm are defined.
Laboratory and diagnostic analyses assume a research of the specific enzymes raising at unstable stenocardia and a heart attack (kreatinfosfokinaza (within the first 4 — 8 hours), troponina-I (for 7 — 10 days), troponina-T (for 10 — 14 days), aminotransferases, laktatdegidrogenaza, a myoglobin (in the first days)). These intracellular proteinaceous enzymes at destruction of kardiomiotsit are released in blood (a rezorbtsionno-necrotic syndrome). Also the research of level of the general cholesterol, lipoproteid low (atherogenous) and high (anti-atherogenous) density, triglycerides, sugar of blood, ALT and nuclear heating plant (nonspecific markers of a tsitoliz) is conducted.
By the most important method of diagnosis of cardiological diseases, including coronary heart disease, the ECG – the registration of electric activity of heart allowing to find violations of a normal operating mode of a myocardium is. – the ultrasonography method of heart allows to visualize the heart sizes, a condition of cavities and valves, to estimate a myocardium sokratimost, acoustic noise. In certain cases at IBS carry out a stress an echocardiography – ultrasonic diagnostics with application of the dosed physical activity, the registering myocardium ischemia.
In diagnosis of coronary heart disease functional tests with loading are widely used. They are applied to identification of early stages of IBS when violations still cannot be defined at rest. As load tests walking, rise on a ladder, the loadings on exercise machines (the exercise bike, a racetrack) which are followed by ECG fixing of indicators of work of heart are used. Limitation of application of functional tests in some cases is caused by impossibility of performance by patients of the required loading volume.
Holterovsky daily monitoring of the ECG assumes the registration of the ECG which is carried out within a day and revealing periodically arising violations in work of heart. For a research the portable device (the holterovsky monitor) fixed on a shoulder or a belt of the patient and taking readings, and also the diary of introspection in which the patient notes the actions and the happening changes in health on hours is used. The data obtained during monitoring are processed on the computer. ECG monitoring allows not only to reveal displays of coronary heart disease, but also the reason and a condition of their emergence that is especially important in diagnosis of stenocardia.
The Chrezpishchevodny electrocardiography (ChPEKG) allows to estimate in details electric excitability and conductivity of a myocardium. The essence of a method consists in introduction of the sensor to a gullet and registration of indicators of work of heart, passing the hindrances created by integuments, hypodermic and fatty cellulose, a thorax.
Carrying out coronary angiography in diagnosis of coronary heart disease allows to contrast vessels of a myocardium and to define violations of their passability, degree of a stenosis or occlusion. Coronary angiography is used for the solution of a question of operation on heart vessels. At introduction of contrast substance the allergic phenomena, including an anaphylaxis are possible.
Treatment of coronary heart disease
Tactics of treatment of the IBS various clinical forms has the features. Nevertheless, it is possible to designate the main directions applied to treatment of coronary heart disease:
- non-drug therapy;
- medicinal therapy;
- carrying out a surgical revaskulyarization of a myocardium (aortocoronary shunting);
- application of endovascular techniques (coronary angioplasty).
Actions for correction of a way of life and food belong to non-drug therapy. At various manifestations of IBS restriction of the mode of activity since at physical activity there is an increase in need of a myocardium for blood supply and oxygen is shown. Dissatisfaction of this requirement of a cardiac muscle actually also causes manifestations of IBS. Therefore at any forms of coronary heart disease the mode of activity of the patient with his subsequent gradual expansion is limited during rehabilitation.
The diet at IBS provides restriction of reception of water and salt with food for decrease in load of a cardiac muscle. For the purpose of delay of progressing of atherosclerosis and fight against obesity the low-fatty diet is also appointed. Are limited, and whenever possible, the following groups of products are excluded: fats of an animal origin (butter, fat, fat meat), smoked and fried food, quickly soaking up carbohydrates (rich pastries, chocolate, cakes, candies). For maintenance of normal weight it is necessary to observe balance between the consumed and spent energy. In need of weight reduction deficiency between the consumed and spent power stocks has to make at least 300 C daily, taking into account that at usual physical activity of people spends per day about 2000 — 2500 C.
Medicinal therapy at IBS is appointed on a formula "A-B-C": antiagregant, β-adrenoblokator and gipokholesterinemichesky medicines. In the absence of contraindications purpose of nitrates, diuretics, antiarrhytmic medicines, etc. is possible. Lack of effect of the carried-out medicinal therapy of coronary heart disease and threat of development of a myocardial infarction are the indication to consultation of the heart surgeon for the solution of a question of expeditious treatment.
To a surgical revaskulyarization of a myocardium (aortocoronary shunting - AKSh) resort for the purpose of restoration of blood supply of the site of ischemia (revaskulyarization) at resistance to the carried-out pharmacological therapy (for example, at stable stenocardia of tension III and IV FC). The essence of the AKSh method consists in imposing of an autovenozny anastomoz between an aorta and the affected artery of heart is lower than the site of its narrowing or occlusion. Thereby the roundabout vascular course delivering blood to the site of ischemia of a myocardium is created. Operations AKSh can be performed with use of artificial blood circulation or on the working heart. The chreskozhny translyuminalny coronary angioplasty (CTCA) – balloon "expansion" of the stenozirovanny vessel with the subsequent implantation a framework-stenta holding a vessel gleam, sufficient for a blood-groove, belongs to low-invasive surgical techniques at IBS.
Forecast and prevention of coronary heart disease
Definition of the forecast at IBS depends on interrelation of various factors. So adversely the combination of coronary heart disease and arterial hypertension, heavy disorders of lipidic exchange and diabetes affects the forecast. Treatment can only slow down steady progressing of IBS, but not stop its development.
The most effective prevention of IBS is decrease in an adverse effect of factors of threat: exception of alcohol and tobacco smoking, psychoemotional overloads, maintenance of optimum body weight, exercises, control HELL, healthy food.