Published: 05/27/2021 11:45:00 Updated: 05/28/2021
Coronary heart disease is a chronic or acutely developing disease characterized by partial or complete cessation of blood supply to the heart muscle.
The cause of this phenomenon is spasm and thrombosis of the coronary arteries, usually due to their atherosclerotic changes.
Organ ischemia is most often manifested by paroxysmal chest pain - angina pectoris; with a sharp and pronounced disturbance of blood flow in the vessels, myocardial infarction develops.
Prevalence of the disease
In Russia, about 5.1-5.3% of the population suffers from ischemic heart disease.
At the same time, coronary heart disease remains the main cause of mortality and disability in the population. Worldwide, deaths from pathologies of the cardiovascular system account for a third of diagnosed cases. In Russia, this figure is higher and amounts to 57%, of which 29% are deaths due to myocardial ischemia. Myocardial ischemia mainly affects people over 40 years of age. In young and middle age, coronary heart disease is more often detected in men; with increasing age, the ratio of cases evens out.
Risk factors for the development of myocardial ischemia
Factors predisposing to this disease are conventionally divided into two groups – modifiable and non-modifiable.
By eliminating or correcting the former, the risk of coronary heart disease is significantly reduced. This group includes situations in which the myocardium needs more oxygen than usual (or oxygen delivery is reduced without increasing its consumption):
- sedentary lifestyle;
- excess weight;
- unhealthy diet – a large amount of fatty and high-calorie foods in the diet;
- psycho-emotional stress;
- bad habits, especially smoking;
- high levels of “bad” cholesterol and triglycerides in the blood;
- high blood pressure – arterial hypertension;
- diabetes;
- endocarditis and heart defects;
- decrease in the concentration of high-density lipoproteins in the blood.
Factors that cannot be changed:
- male gender;
- age over 65 years;
- IHD, especially myocardial infarction in the past in close relatives of the patient;
- the onset of menopause.
The likelihood of coronary heart disease in women increases significantly with the onset of menopause.
Diagnosis of acute ischemia during examination by a vascular surgeon
The classic picture of acute ischemia is determined by six symptoms:
- Sudden leg pain
- Pale skin
- Absence or deficit of movement in the affected limb
- Absence of pulse in the affected limb
- Decreased skin sensitivity
- Decreased skin temperature
The pain may be constant or with passive movement of the affected limb. With an embolic blockage, the pain is usually sudden and very intense. With thrombosis, the pain intensity is much less, and sometimes there is a progressive increase in intermittent claudication.
Symptoms and forms of IHD
With different forms of coronary heart disease, symptoms may differ. There are several forms of the disease.
Angina pectoris
The condition is characterized by attacks of squeezing or burning pain behind the sternum, which usually appears during physical and emotional stress.
It can radiate to the left arm, neck, shoulder, lower jaw, subscapular region, upper abdomen. For this reason, angina pectoris is also called “angina pectoris.” The duration of pain is usually several minutes. Depending on the stability of the course of the disease, stable and unstable forms of angina are distinguished. The first occurs only after physical or psycho-emotional stress, with increased blood pressure, tachycardia. As the disease progresses, the amount of activity available to a person decreases, and in the fourth class of pathology, he can no longer make any movement without developing attacks of chest pain.
Unstable angina can be new - a month or less after the onset of symptoms, progressive and early post-infarction. Progressive angina is characterized by a decrease in the load tolerated, for example, a decrease in the distance that a person can walk without the appearance of symptoms.
Unstable angina requires examination and treatment in a hospital; the risk of myocardial infarction is high.
Myocardial infarction
Develops acutely.
Due to a prolonged decrease in blood flow or its complete cessation to certain areas of the heart muscle, necrosis of the area of the heart muscle occurs - necrosis. The affected area can be of different sizes depending on the diameter of the affected vessel, which is why the disease is often called large-focal or small-focal myocardial infarction. The pain in this condition is intense, pressing and squeezing in nature, and attacks of burning “dagger” pain are also common. In many patients, it has a typical localization in the retrosternal region, but it can also involve the area to the left of the sternum or spread to the entire surface of the chest. In this case, the patient experiences “fear of death”, melancholy, a feeling of doom arises, and may be restless and very excited.
The localization of pain during myocardial infarction can be almost any; for example, sometimes pain occurs even in the abdomen. There is also a painless form.
With small focal lesions, the symptoms may be blurred, and diagnosis by ECG can be difficult.
Spontaneous Prinzmetal ischemia
Substernal pain occurs against the background of spasm of the coronary vessels and is not associated with exercise. Most often, the condition develops at night, between midnight and eight o'clock in the morning. Spastic angina is characterized by regularity and cyclicity, often repeating several attacks in a row with a short interval.
Post-infarction cardiosclerosis
After a heart attack, dead muscle cells are replaced with connective tissue. In this case, conductivity in the myocardium is disrupted, which may be accompanied by sensations of interruptions in the work or prolonged cardiac arrest, periodic fainting and dizziness. There may also be attacks of rapid heartbeat, chest pain, shortness of breath, pale or blue discoloration of the skin.
Heart failure
A disease in which the heart cannot fully perform its function of providing the tissues of various organs with a sufficient amount of blood. The condition is manifested by shortness of breath, swelling, fatigue, and poor tolerance to physical activity.
Heart rhythm disturbances
Arrhythmias are of various types. Accompanied by a feeling of palpitations or a decrease in heart rate. The patient may experience severe weakness, dizziness, nausea, and possible loss of consciousness. There are also asymptomatic forms of pathology, which become an accidental finding on the ECG.
Silent myocardial ischemia
It occurs without characteristic attacks of angina pectoris. It is usually detected accidentally on an ECG and after special diagnostic exercise tests.
Sudden cardiac death
More often it occurs due to ventricular fibrillation or flutter - erratic contraction of the heart muscle at high frequency. The condition develops unexpectedly and is manifested by the following symptoms:
- weakness;
- dizziness;
- loss of consciousness;
- noisy and rapid breathing;
- dilated pupils;
- decrease in respiratory rate;
- absence of heart contractions.
Sometimes the heart can be returned to the correct rhythm, but if this was not done in the first minutes, then the brain cells die from hypoxia, and an irreversible coma develops.
Case from practice
In my practice, there was one particularly significant case of silent myocardial ischemia.
A man was admitted to the emergency department with a referral for hospitalization issued by a local physician. Patient N., 54 years old, had absolutely no complaints. Went in for a scheduled annual inspection from my place of work. History of alcohol abuse for 10 years. Objectively, the excess weight attracted attention. Several ECGs taken in the clinic showed a downward-sloping depression of the ST segment of 1-2 mm, which lasted no more than a minute. Several such episodes were observed on the cardiogram. The patient was hospitalized in the department with a preliminary diagnosis: “Silent myocardial ischemia.”
In the department, he underwent Holter ECG monitoring, ECG with stress tests (treadmill), cardiac CT with intravenous enhancement, biochemical and clinical analysis of blood and urine. The changes revealed during the examination confirmed the previously made diagnosis.
The patient was prescribed Bisoprolol, Amlodipine, Sidnopharm, Cardiomagnyl, Preductal. Subsequent ECGs showed positive dynamics. The patient was discharged after seven days with recommendations to continue taking the prescribed medications, avoid alcohol consumption, and attend a routine examination with the local physician within a week.
Diagnosis of coronary heart disease
Usually, complaints and symptoms characteristic of coronary heart disease help to suspect the disease.
To confirm myocardial ischemia, instrumental and laboratory diagnostic methods are used. Tests for coronary heart disease may include:
- Leukocytosis and decreased hemoglobin in a general blood test.
- Increased cholesterol and glucose, changes in the lipid profile according to biochemical blood tests.
- An increase in specific enzymes formed during the destruction of cardiomyocytes - creatine phosphokinase (its special fraction - MB) during the first 3-4 hours of a heart attack (lasts 48-72 hours), troponin-I, troponin-T (their level increases 6 hours after a heart attack and remains elevated for 7-14 days), aspartate aminotransferase (AST) (exceeds the normal level 8-12 hours after the onset of pain, normalizes within 3-4 days), lactate dehydrogenase (begins to exceed the normal level 14-48 hours after the onset of symptoms, returns to normal on days 7-14), myoglobin (increases 2 hours after the onset of symptoms and normalizes within 24 hours) in the blood.
- Elevated C-reactive protein and homocysteine levels are a risk for sudden cardiovascular events.
- Increased blood clotting according to the results of a coagulogram may also increase the risk of developing certain forms of coronary artery disease.
Instrumental research methods can be invasive or non-invasive. In the latter case, the following is used to diagnose coronary heart disease:
- electrocardiography;
- ultrasound examination of the heart - Echo-CG;
- Holter ECG monitoring;
- stress ECG tests: treadmill and bicycle ergometry;
- PET/CT of the heart.
Functional load tests are widely used.
They are used, among other things, to detect the early stages of coronary artery disease or a painless form of the pathology, when the disorders cannot be determined at rest. Walking, climbing stairs, exercises on exercise machines (an exercise bike, a treadmill), accompanied by ECG recording of current indicators, are used as stress tests for suspected coronary heart disease. The standard and most accurate method for this is diagnostics using a treadmill (treadmill) and an exercise bike (bicycle ergometry). Positron emission tomography (PET) is used to diagnose viable cardiac muscle cells. Radiopharmaceuticals are used, the accumulation of which in heart cells reveals viable and necrotic areas.
Among the invasive techniques, coronary angiography is used - x-ray examination of blood vessels using a contrast agent.
Treatment of coronary artery disease
Treatment for coronary heart disease includes lifestyle changes, medications and, in some cases, surgery.
All patients are advised to give up bad habits, spend more time in the fresh air, and reduce excess body weight. In your diet, you must avoid foods high in fat, very salty and sweet foods. Smoking and unauthorized discontinuation of prescribed medications are strictly prohibited. All this can lead to a sharp deterioration in the patient's condition. To stop an attack of angina, you need to immediately stop physical activity, provide access to fresh air and take nitroglycerin under the tongue or use nitrate in the form of a spray.
Basic drug therapy includes the following drugs:
- antiplatelet agents – drugs that thin the blood;
- beta blockers;
- ACE inhibitors or sartans;
- statins.
Long-acting nitrates can be used to prevent attacks.
In the presence of concomitant diseases, especially diabetes mellitus and hypertension, their treatment and achievement of target blood pressure and glucose levels are required.
To restore cardiac blood flow, surgical intervention is necessary in some cases:
- Coronary artery bypass surgery is the creation of a bypass for blood at the site of narrowing of the coronary arteries using vascular prostheses.
- Coronary angioplasty and stenting - restoration of the diameter of the vessel, and, accordingly, the blood flow in it, by installing a special dilator.
Ultrasound duplex scanning
Ultrasound duplex scanning allows you to determine the patency of the arteries, localize the site of blockage of the vessel and the state of blood flow below the site of occlusion. Often, in acute ischemia, this diagnosis is enough to determine treatment tactics and send the patient to the operating table. With an embolism or rupture, the arteries below the blockage are usually empty or thrombosed, and blood flow in them is not detectable. Blood flow in the veins is sharply slowed down. With thrombosis, blood flow can be detected below the site of blockage, but its speed is sharply reduced; most often, blood flow through the main vessels cannot be detected, but blood flow can be seen through collaterals. As a rule, this is due to
Measures to prevent cardiovascular pathology
To avoid developing heart disease, you need to stop smoking and reduce your alcohol consumption.
Severe stress is also one of the predisposing factors to the occurrence of IHD. It is impossible to remove stress from life, but you can react to it correctly: humans are evolutionarily designed in such a way that muscle work is necessary after any stress. If you are worried or upset, then you need to squat, jog, or walk – the muscles should get tired. In case of severe anxiety, you may need to use sedatives, for the selection of which you need to consult a doctor.
Regular exercise with moderate physical activity is useful for the prevention of ischemia. You also need to monitor your weight and blood pressure. All persons over 40 years of age must be examined annually - take a biochemical blood test to check the level of cholesterol in the blood, and do an ECG.
Author:
Baktyshev Alexey Ilyich, General Practitioner (family doctor), Ultrasound Doctor, Chief Physician
