Internal illnesses. Coronary heart disease (lecture notes)

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Internal illnesses. Coronary heart disease (lecture notes)

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LECTURE No. 15. Ischemic heart disease

Ischemic heart disease is myocardial damage caused by a disorder of the coronary circulation, resulting from an imbalance between the coronary blood flow and the metabolic needs of the heart muscle.

Etiology. Atherosclerosis of the coronary arteries, vasospasm, disturbances in the hemostasis system (changes in platelet function, increased blood clotting activity, inhibition of fibrinolysis), an underdeveloped network of collateral circulation, hyperproduction of catecholamines are of primary importance.

Pathogenesis. With angina pectoris, there is a discrepancy between the blood supply to the myocardium and its needs, the development of ischemia. With myocardial infarction, insufficient blood supply to the myocardium occurs with the development of lesions and necrosis in it.

Classification. In clinical practice, the classification of coronary heart disease according to E. I. Chazov (1992) is used:

1) sudden death (primary cardiac arrest);

2) angina pectoris: angina pectoris, first appeared, stable (I-IV FC (functional class), progressive, spontaneous angina pectoris;

3) myocardial infarction: macrofocal (transmural), small focal;

4) postinfarction cardiosclerosis.

Clinic.

Angina pectoris

For the first time angina pectoris characterized by pain syndrome lasting less than 1 month.

With stable angina I functional class pain syndrome occurs during accelerated walking or walking with an average step of up to 1000 m (VEM (veloergometry) - 750 kgm / min.

With stable angina II functional class pain syndrome occurs when walking on flat terrain up to 500 m (VEM - 450 kgm / min).

With stable angina III functional class pain syndrome occurs when walking on flat terrain up to 150-200 m (VEM - 150-300 kgm / min).

With stable angina IV functional class there is an inability to perform any load without an attack of angina pectoris (VEM is not performed).

Progressive angina characterized by a sudden increase in the frequency and duration of seizures with the same degree of physical activity.

Spontaneous (vasospastic or Prinzmetal's variant angina) occurs at night.

With angina pectoris, pain is more often localized behind the sternum with irradiation to the left arm, shoulder blade, neck, sometimes to the left half of the jaw, has a compressive burning character, pain duration from 5-10 minutes to 25-30 minutes. The pain is relieved at rest, after taking nitroglycerin. Possible bradycardia or tachycardia, rise in blood pressure.

Myocardial infarction

The first period represents the period of precursors (prodromal). First-time angina, progressive angina, vasospastic angina may be noted. The most acute period lasts up to 2 hours. The duration of the acute period is up to 8-10 days, there are the following course options:

1) anginal (chest pain for more than 20 minutes), restlessness, cold sticky sweat, nausea, vomiting;

2) gastralgic (pain in the epigastric region);

3) asthmatic (acute left ventricular failure);

4) arrhythmic (acute rhythm disturbances);

5) cerebral (insufficiency of cerebral circulation);

6) asymptomatic (lack of clinical manifestations).

This is followed by a subacute period lasting up to 4-8 weeks. Then the postinfarction period lasting up to 2-6 months develops.

In myocardial infarction, the main syndromes are pain, arrhythmia, circulatory failure, resorption-necrotic.

The pain syndrome differs in intensity, duration (from several hours to a day or more). The pain has a pressing, compressive, cutting, tearing character, is localized more often behind the sternum, less often captures the entire anterior chest wall. The pain radiates to the left shoulder, arm, sometimes jaw, epigastric region, is not removed by nitroglycerin, sometimes by drugs. Patients are excited, experience fear of death. The skin is pale, the mucous membranes are cyanotic, bradycardia develops, more often moderate tachycardia, a short-term increase in blood pressure. Heart sounds are weakened, a proto-diastolic gallop rhythm can be heard.

Additional diagnostic study. A general blood test is mandatory: with angina pectoris it has no diagnostic significance, and with myocardial infarction, manifestations of resorption-necrotic syndrome are noted (an increase in the level of leukocytes in the peripheral blood on the first day, after 2-3 days an increase in ESR with a gradual decrease in the number of leukocytes).

The levels of transaminases specific for myocardial infarction are studied: myoglobin, creatine kinase microfraction (MB-CK mass) - early markers of myocardial damage; troponin, creatine kinase microfraction (MB-CK) - late markers of myocardial damage. With myocardial infarction, there is an increase in transaminase activity, but these indicators do not apply to specific tests. It is necessary to take into account the de Ritis coefficient (AST / ALT ratio), which increases more than 1,33 with myocardial damage.

A biochemical blood test is carried out to determine cholesterol, triglycerides.

ECG study: with angina pectoris, there is no change in the ECG during the pain-free period, with pain, a horizontal displacement of the ST interval below the isoelectric line by more than 1 mm with exertional angina and a rise in the ST segment above the isoline by more than 1 mm with rest angina. With myocardial infarction, a pathological Q wave appears with a depth of more than 1/3R and a width of more than 0,03, there is a shift in the ST interval upward from the isoline and negative T.

In angina pectoris, coronary angiography is recommended.

Stress tests are carried out to determine the functional class of angina pectoris, to resolve expert issues after myocardial infarction.

In the presence of contraindications to stress tests and the establishment of a spasm of the coronary arteries, pharmacological tests are performed.

An echocardiographic study is performed to assess the functional parameters of the heart muscle, to detect hypokinesia and akinesia of the myocardium.

Complications. Early complications include cardiogenic shock, pulmonary edema, rhythm and conduction disturbances, myocardial ruptures (cardiac tamponade), acute cardiac aneurysm, pericarditis, thromboendocarditis, clinical death (ventricular fibrillation).

Late complications are angina pectoris, heart failure, myocardial rupture, thromboembolism, arrhythmias, Dressler's syndrome (pericarditis, pleurisy, pneumonitis), arrhythmias, chronic heart aneurysm.

Treatment. With angina pectoris a pain attack is relieved by taking nitroglycerin, with a progressive form of angina pectoris, vasodilators and non-narcotic analgesics are introduced.

For the prevention of recurrent attacks, it is recommended to limit physical activity, combat hypertension, obesity, diabetes mellitus, hypercholesterolemia, and smoking.

Drug treatment includes the use of long-acting nitrates, nitrate-like agents - nitrong, sustak, sustanite, nitrosorbitol, sydnopharm, erinite. Of the calcium antagonists, cordafen, corinfar, verapamil are used. Of the β-blockers, atenolol, metaprolol (egilok), nebivolol (nebilet), etc. are used. Antiarrhythmic drugs, antispasmodics (if indicated), anabolic agents, prodectin are used.

Surgical treatment includes coronary artery bypass grafting, percutaneous transluminal angioplasty.

With myocardial infarction pain relief is carried out with narcotic analgesics, fentanyl with droperidol, anesthesia with nitrous oxide, epidural anesthesia.

With the duration of the pain syndrome up to 6 hours, thrombolytic and anticoagulant therapy is carried out. It is possible to introduce streptase, streptodecase, heparin, indirect anticoagulants.

Nitrates, β-blockers are used to prevent an increase in the necrosis zone.

In the subacute period, long-acting nitrates, indirect anticoagulants are used to strengthen the coronary circulation.

With the development of complications, their appropriate treatment is carried out.

Flow. With angina pectoris, the course is undulating, depending on the degree and progression of atherosclerosis of the coronary arteries. In myocardial infarction, the course can be uncomplicated, complicated, protracted and recurrent.

Forecast. With angina pectoris, the prognosis depends on the severity of atherosclerosis of the coronary arteries, on the frequency of angina attacks. With myocardial infarction in the absence of complications, the prognosis is favorable, and with complications - serious.

Prevention. Primary prevention includes the following activities: identification of risk factors, rational organization of the regime of work and rest. Secondary prevention includes dispensary observation of persons with unstable forms of angina pectoris, arterial hypertension.

Author: Myshkina A.A.

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