2DEFINITIONIHD - synonims – coronary disease, coronary insufficiency – is severe chest pain due to ischemia (a lack of blood and hence oxygen supply) of the heart muscle, generally due to obstruction or spasm of the coronary arteries (the heart's blood vessels).
3RISK FACTORSSmoking alcohol abuse high arterial pressure Dislipidemia Diabetes mellitus Obesity Excessive consumption of animal fats thrombogenic factors Lack of physical activity
5Causes of IHD 85 % - stenotic atherosclerosis of coronary arteries 10 % - spasm of coronary arteries5 % - transitory thrombocytes aggregates100 % - combination of these factorsMorbidity in males is 4 times higher than in females
11AtherosclerosisDistributed chronic disease characterized by specific lesions of arteries of elastic and muscular types as growths in the walls of connective tissue with lipid infiltration of the inner shell. This leads to organ and total circulatory disorders.
12ComplaintsComplaints and clinical manifestations are determined by the localization of atherosclerotic plaques, their vulnerability and the degree of occlusion of the vascular lumen. Examples of localization of the pathological process: *in the coronary arteries - coronary heart disease *in the vessels of the lower extremities - atherosclerosis *vessels of the brain - the cerebral circulation disorders.
13Atherosclerosis is a pathologic basis of coronary heart disease, brain and peripheral arteries diseases. These diseases cause over 60% mortality from all diseases in developed countries.
14Classification1.Preclinical, hidden period: nervous, vasomotor and metabolic disorders. 2. Period of clinical manifestations *The first stage (ischemic) - vasoconstriction, leading to disruption of trophic and dystrophic changes in the relevant organs. *The second stage (thrombo necrotic) – micro- or macrofocal necroses with vessel thrombosis without them. *The third stage (sclerotic or fibrotic) - development of fibrous, cicatricial changes in the organs with atrophy of the parenchyma.
16Functional research methods 1. Electrocardiography using pharmacological and exercise testing to detect coronary artery disease 2. Echocardiography (left ventricular hypertrophy). 3. Visualizing the walls of arteries and differentiation of elements of atherosclerotic plaque by MRI. 4. Determination of coronary calcificates using computed tomography.
18The accumulation of cholesterol in the vascular wall - atherosclerotic plaque
19Laboratory diagnostic Total cholesterol less than 5 mmol / l LDL cholesterol less than 3 mmol / l HDL Cholesterol higher than 1 mmol / l Triglycerides less than 2 mmol / l
20TreatmentDiet Changing lifestyles Statins - drugs for the correction of lipid metabolism. Fibrates - prevent the absorption of lipids in the intestine.
21Clinical forms of IHD 1. Sudden coronary death or heart arrest (HA) 2. Angina pectoris (AP)2.1 Stable angina at exertion.2.1.1 Stable angina at exertion ( functional class should be determined).2.1.2 Stable angina at exertion in angiographically intact vessels (coronary syndrome X).
27Stable angina at exertion Occurs in the same provoking factors, is often follows with the same complains and changes on ECG.
28AP functional classesІ FC – attacks occur in a whery high load 1 – 2 times a year. Coronary arteries lumen is narrowed not more than on 50 %.ІІ FC – attacks occur in walking on the plane surface on the diastance more than 500м, in going more than on 1 floor upstairs 2 – 3 times a week. Coronary arteries lumen is narrowed not more than on 75 %.
29ІІІ FC – attacks occur in walking on the plane surface on the diastance 200 – 300 м, in going 1 floor upstairs. Postinfarctional angina. Coronary arteries lumen is narrowed more than on 75%.ІV FC – attacks occur in walking on the plane surface on the diastance less than on 100 м, in rest. Combination of coronary and myocardial insufficiency. Complete obturation of coronary arteries.
30Clinical patternThe major sign of stenocardia is attack-like pain in the area of heart. It has squeezing, cutting or burning character with localization behind a breastbone, irradiates in a left arm (left shoulder-blade, left half of neck, lower jaw, sometimes – in a right shoulder or shoulder-blade). Duration of pain of 5-10 min (more frequently – 2-5 min).
36Coronary syndrome XThis is a stable angina at exertion when small coronary arteries are affected.Clinical pattern is the same as for stable angina but coronarography does not show obturation of coronary arteries.
37Angiospastic anginaCaused by spasm of coronal arteries. Arises up in young persons, mainly at night, in rest, when tone of vagus nerve prevails. Duration of attack till 30 min, during this time ECG shows changes typical for MI (depression of ST segment) which disappear after stopping of attack or application of spasmolysants. Nitrates are uneffective with the purpose of removal of attacks.
39Acute coronary syndrome This is a result of myocardial ischemia caused by thrombosis of coronaty artery and its complete occlusion.The syndrome includes:1. Unstable angina pectoris.Non-Q myocardial infarction.3. Q- myocardial infarction.
40Unstable angina pectoris At a stenocardia which arose up first, the attacks of pain are observed during 28 days for persons, which did not have clinical signs of stenocardia before. Usually this is angina at exertion.Progressing angina is the state, at which duration, intensity and frequency of anginal attacks, grow in a dynamics, and the usual dose of medications which take off an attack becomes insufficient, that requires its permanent increase.
41Characteristic for progressing stenocardia is pressing pain behind the sternum, which periodically calms down and grows, is not removed by nitrates, is accompanied with swweating, dyspnea, arrhythmia, fear of death. The episodes of attacks of anginal pain become more frequent, and periods between attacks shorten.Every next attack is heavier, than previous. Nitrates (nitroglycerine, Nitrosorbidum), which removed the attacks of anginal pain before, are uneffective, although a patient uses considerably increased their amount.
42Associated manifestations Pain can arise up not obviously due to emotional or physical loading, but also in rest. Sometimes only narcotic facilities remove him. On a background a stenocardia there can be an attack of sharp left-ventricular insufficiency with dyspnea, dry cough, bubbling in the chest.
43Diagnostics of angina pectoris functional tests:- exposure to cold;- test with hyperwentilation;tests with dynamic physical load:а) veloergometry;б) tredmile test;emotional stress-test;pharmacological tests;а) test with dityridamole;б) test with isadrine;в) test with ergometrine;transesophageat atrial electrostimulation;daily ECG-mpnitoringcoronary angiography.
46Laboratory examinations Complete blood count – 1 time a yearByochemical blood serum study (lipid spectre, cholesterol - 1 time a year)ЕCG and functional tests – 2-3 times a year in stable angina depending on functional class.
48TreatmentHealthy life stile. Correction of risk factors, limitation of carbonhydratess and saturated fats in diet. Employment. Psychprrophylaxis.Medication (nitrates, other antianginal preparations on a sedate agents) depending on a functional class and concomitant diseases. Sanatorium-resort treatment.