Ischemic cardiomyopathy

Ischemic cardiomyopathy (ICM) is a heart condition that develops as a result of ischemia of the heart muscle, that is, insufficient blood and oxygen supply to the heart muscle. This condition can occur due to narrowing or blockage of the coronary arteries that supply blood to the heart. Ischemic cardiomyopathy can lead to deterioration of heart function and the development of heart failure.

Important risk factors for the development of ischemic cardiomyopathy are atherosclerosis (cholesterol deposition on arterial walls), arterial hypertension (high blood pressure), smoking, diabetes, lipid metabolism disorders, family predisposition and other factors that contribute to the development of atherosclerosis.

The main symptoms of ischemic cardiomyopathy may include:

1. Chest pain or pressure (angina) that may occur with exercise or stress.
2. Shortness of breath and fatigue.
3. Feeling a strong heartbeat or irregular heart rhythms.
4. Swelling (e.g., swelling of the legs).
5. Weakness and deterioration in general health.

The diagnosis of ischemic cardiomyopathy is usually made after various investigations such as ECG, echocardiography, coronarography and cardiac exercise tests. Treatment of ICM includes correction of risk factors (e.g., treatment of arterial hypertension, smoking cessation), drug therapy to improve blood flow to the heart and manage symptoms, and sometimes surgery such as angioplasty with stenting or coronary artery bypass grafting. Treatment may also include lifestyle changes such as regular exercise, diet and moderate alcohol consumption.

Early medical attention and adherence to treatment recommendations can significantly improve the prognosis for patients with ischemic cardiomyopathy. [1]

Causes of the ischemic cardiomyopathy

Here are the main causes of ischemic cardiomyopathy:

1. Coronary artery atherosclerosis: The most common cause ofcoronary cardiomyopathy is atherosclerosis, which causes plaques to form inside the arteries, narrowing or blocking them. This interferes with the normal blood supply to the heart muscle.
2. Coronary artery stenosis: St enosis, or narrowing, of the coronary arteries can also cause coronary cardiomyopathy. This can be due to atherosclerosis as well as other factors.
3. Thrombosis or embolism: The formation of blood clots (blood clots) in the coronary arteries or an embolism (part of a clot or plaque breaking off) can also block the blood supply to the heart and cause coronary cardiomyopathy.
4. Arterial hypertension: A persistent increase in blood pressure can increase the workload on the heart and lead to the development of ischemic cardiomyopathy.
5. Diabetes: Diabetes mellitus is a risk factor for atherosclerosis and ischemic cardiomyopathy, as it can damage vessel walls and promote plaque formation.
6. Smoking: Smoking is a risk factor for atherosclerosis and therefore for ischemic cardiomyopathy.
7. Genetic predisposition: Hereditary factors may also play a role in the development of this disease.
8. Other risk factors: This includes obesity, physical inactivity, poor diet, excessive alcohol consumption and stress.

Pathogenesis

The pathogenesis of ICM is related to various factors that ultimately lead to deterioration of cardiac muscle function. Here are the main steps in the pathogenesis of CHF:

1. Coronary artery atherosclerosis: The main cause of CAD is atherosclerosis, in which the inner layer of the arteries (intima) becomes damaged and fatty deposits, called plaques, build up. These plaques can grow in size and usurp the lumen of the arteries, which narrows or blocks the flow of blood to the heart muscle.
2. Ischemia: Narrowing or blockage of the coronary arteries leads to limited oxygen supply to the heart, which causes ischemia. Lack of oxygen can cause chest pain (angina pectoris) and damage heart cells.
3. Heart cell destruction: In chronic ischemia, heart cells may begin to die due to lack of oxygen. This process is called necrosis and can lead to an area of dead tissue in the heart.
4. Cardiac remodeling: Permanent damage to heart cells and necrosis leads to remodeling of the heart. This means that the heart muscle becomes less able to contract and pump blood efficiently.
5. Heart failure: As a result, the heart may lose its ability to maintain normal cardiac blood output, leading to the development of heart failure. Patients with ICM may experience symptoms such as shortness of breath, fatigue, and swelling.

Risk factors such as smoking, high blood pressure, diabetes, and lipid metabolism disorders can exacerbate the development of atherosclerosis and ischemic cardiomyopathy.

Symptoms of the ischemic cardiomyopathy

Symptoms of ischemic cardiomyopathy can be similar to those of coronary heart disease (CHD) and include:

1. Chest pain (angina pectoris): Pain or pressure in the chest area that may spread to the neck, shoulders, arms, or back. The pain usually occurs with exercise or stress and may subside at rest or after taking nitroglycerin.
2. Shortness of breath: Short- or long-term shortness of breath during physical activity or even at rest.
3. Fatigue and weakness: Constant fatigue and weakness, especially with light exertion.
4. Heart palpitations: Unusual heart rhythms, pulsation, or sensation of palpitations.
5. Swelling: Swelling in the legs, shins, ankles, or even the abdomen.
6. Dizziness and loss of consciousness: These symptoms can occur when the heart cannot provide enough blood and oxygen to the brain.
7. Weight loss: Weight loss with no apparent cause.
8. Headaches: Headaches, sometimes caused by hypoxia (lack of oxygen) due to poor blood supply.

Stages

Ischemic cardiomyopathy can go through several stages depending on the severity and duration of the disease. The stages of ICM include the following:

1. Latent or preclinical stage: In this stage, the patient may have risks for coronary cardiomyopathy, such as coronary artery atherosclerosis, but may not yet show symptoms. It is important to have regular medical examinations and control risk factors.
2. Angina pectorisstage: In this stage, the patient begins to experience pain or pressure in the chest (angina pectoris) in response to exercise or stress. This is usually due to a temporary disruption in the blood supply to the heart muscle due to narrowing of the coronary arteries.
3. Acute ischemia stage: In this stage, more severe and prolonged episodes of ischemia (lack of blood supply to the heart) occur. The patient may experience myocardial infarctions (heart attacks) and have significant damage to the heart muscle.
4. Chronic ischemia stage: After several myocardial infarctions and/or prolonged ischemia of the heart muscle, chronic ischemic cardiomyopathy may develop. In this stage, the heart muscle may lose its ability to contract and pump blood efficiently, leading to a decline in heart function.
5. Heart Failure Stage: Eventually, CHF can lead to the development of heart failure, when the heart is unable to pump blood efficiently throughout the body. This can be manifested by shortness of breath, swelling, weakness, and other symptoms.

The severity level and progression of ICM can vary from patient to patient. [2]

Complications and consequences

Ischemic cardiomyopathy can cause serious complications and have serious health consequences for the patient, especially if it is not treated properly or if the patient does not follow treatment recommendations. The following are some of the possible complications and consequences:

1. Heart failure: ICM can lead to an impaired ability of the heart to pump enough blood to meet the body's needs. This can cause symptoms such as shortness of breath, swelling, and fatigue.
2. Myocardial Infarction: ICM is one of the risk factors for myocardial infarction (heart attack) because it is associated with atherosclerosis and narrowing of the coronary arteries.
3. Arrhythmias: Ischemic cardiomyopathy can cause heart rhythm disturbances, including atrial fibrillation and ventricular fibrillation. These arrhythmias can be dangerous and may require treatment.
4. Swelling: Heart failure, which can be a complication of ICM, can cause swelling in the legs, shins, ankles, or even the lungs.
5. Death: In severe cases of ICM, especially if untreated, it can lead to fatal complications such as acute heart failure or myocardial infarction.
6. Activity Limitation: ICM can limit a patient's physical activity and impair their quality of life.
7. Psychological and emotional problems: Serious heart disease can cause stress, anxiety and depression in patients.
8. Surgical interventions: In some cases, ICM may require surgical procedures such as angioplasty or coronary artery bypass grafting.

Diagnostics of the ischemic cardiomyopathy

Diagnosis of ischemic cardiomyopathy includes a number of clinical, instrumental, and laboratory methods that help determine the presence and extent of heart damage. Here are the main methods of diagnosing ICM:

1. Clinical assessment:
   • Gathering medical and family history: The physician asks questions about symptoms, risk of developing ICM, presence of medical conditions in the family, and other risk factors.
   • Physical Exam: The doctor performs a general physical exam, including listening to the heart and lungs, assessing pulse, blood pressure, and signs of heart failure.
2. Electrocardiography (ECG): An ECG records the electrical activity of the heart. ECG changes such as ST-T segment changes may be seen in patients with ICM, which may indicate ischemia of the heart muscle.
3. Echocardiography (cardiac ultrasound): Echocardiography uses ultrasound waves to create an image of the heart and its structures. This method can assess the size and function of the heart, detect changes in the contractility of the heart muscle, and identify valve lesions.
4. Myocardial scintigraphy: This is a radioisotope study that can identify areas of heart muscle with limited blood supply.
5. Coronarography: This is an invasive test in which a contrast agent is injected through a catheter into the coronary arteries to assess their condition and detect possible blockages. Coronarography can be used to plan surgical procedures such as angioplasty or coronary artery bypass surgery.
6. Blood tests: Laboratory tests may include measuring creatinine kinase (CK) and cardiac-specific troponin levels, which may indicate heart muscle damage.
7. Exercise test: A stress ECG or stress test can be used to detect ischemia during physical activity.

The diagnosis of ICM requires a combination of different methods, and the choice of specific investigations depends on the clinical situation and the physician's recommendations.

The diagnosis of ischemic cardiomyopathy (ICM) is usually made based on a constellation of clinical symptoms, laboratory and instrumental findings. Here are some of the criteria and methods used to diagnose ICM:

1. Clinical Symptoms: The patient may complain of symptoms such as angina (chest pain or pressure), shortness of breath, fatigue, irregular heartbeat, and other signs of cardiac abnormalities. It is important to perform a thorough examination and interview the patient to identify characteristic symptoms.
2. Electrocardiogram (ECG): An ECG can reveal changes in heart rhythm and electrical activity that are characteristic of ICM. This may include the presence of arrhythmias, areas of slowed conduction, and changes in the shape and duration of QRS complexes.
3. Echocardiography (cardiac ultrasound): Echocardiography can help visualize the structures and function of the heart. With ECM, changes in heart wall structure and contractile function can be detected.
4. Coronarography: This is an invasive test that uses a contrast agent to visualize the coronary arteries. If stenosis (narrowing) of the arteries is found, it can confirm the presence of ischemia and AKI.
5. Cardiac monitoring: Long-term ECG monitoring can help detect arrhythmias and changes in cardiac activity that may be characteristic of ICM.
6. Biomarkers: Elevated levels of biomarkers such as troponins and creatine kinase-MB may indicate cardiac muscle damage, which can occur in ICM.
7. Investigation of medical history and risk factors: The doctor will also review the patient's medical history, including the presence of risk factors such as hypertension, diabetes, smoking, hereditary predisposition, and others.

A combination of different methods and investigations is often required to establish the diagnosis of AKI. It is important that the diagnosis is made by a cardiologist, and in case of suspected AKI, a specialist should be consulted for more detailed examination and treatment.

Differential diagnosis

The differential diagnosis of ischemic cardiomyopathy (ICM) involves identifying and distinguishing this condition from other conditions that may have similar symptoms or characteristics. It is important to correctly identify ICM in order to provide the patient with the best treatment and management of their condition. Here are a few conditions that may be included in the differential diagnosis of ICM:

1. Hypertrophic cardiomyopathy (HCM): HCM is a condition in which the walls of the left ventricle are too thick, which can lead to similar symptoms to HCM, such as angina and fatigue. However, HCM has other characteristic features on echocardiography that help in the differential diagnosis.
2. Hypertensive cardiomyopathy: Hypertensive cardiomyopathy is associated with arterial hypertension (high blood pressure). It can cause left ventricular wall thickening and angina pectoris. Determining and monitoring blood pressure levels can help in the differential diagnosis.
3. Aortic StenosisSyndrome: Aortic stenosis is a narrowing of the heart's aortic valve, which can cause angina and other symptoms similar to ICM.
4. Pulmonaryhypertension: Pulmonary hypertension is increased pressure in the pulmonary arteries, which can also cause shortness of breath and fatigue similar to the symptoms of ICM.
5. Other Causes of Chest Pain: Chest pain can be caused by a variety of reasons such as osteochondrosis, breathing problems, and even anxiety conditions.

To make a differential diagnosis of ICM, a doctor may perform a number of tests, including an electrocardiogram (ECG), echocardiography, coronarography (contrast angiography of the heart), and a review of the patient's medical history and symptoms.

Treatment of the ischemic cardiomyopathy

Ischemic cardiomyopathy (ICM) is a serious condition, and treatment involves a comprehensive approach that may include drug therapy, surgery, and lifestyle changes. Here are the main aspects of ICM treatment:

1. Drug therapy:

   • Cholesterol-lowering drugs: Statins can help lower blood cholesterol levels and slow the progression of atherosclerosis.
   • Blood pressure medications: Beta-blockers, angiotensin-converting enzyme inhibitors (ACEIs), and other medications are used to control blood pressure and reduce the workload of the heart.
   • Drugs to reduce the strain on your heart: Nitrates and antianginal medications can help relieve chest pain and reduce the strain on your heart.
   • Antiplatelet drugs: Aspirin and other drugs are used to prevent blood clots from forming in blood vessels.

2. Surgical methods:

   • Coronary bypass surgery: This is a surgery in which "shunts" (transfers) are created around narrowed or blocked areas of the coronary arteries to restore normal blood flow to the heart.
   • Angioplasty and stenting: Procedures in which narrowed arteries are widened and a stent (prosthesis) is placed to keep the vessel open.

3. Treatment of heart rhythm disorders: If a patient has ICM accompanied by arrhythmias, treatment may be needed to eliminate or control the arrhythmias.

4. Lifestyle changes:

   • Healthy eating: Following a diet that limits fat and salt can help control risk factors.
   • Physical activity: Regular exercise, supervised by your doctor, can strengthen your heart and blood vessels.
   • Smokingcessation: Smoking is a serious risk factor for ischemic cardiomyopathy.
   • Stress Management: Practicing relaxation, meditation and maintaining psychological well-being can reduce stress and have a positive impact on heart health.

5. Regular follow-up with your doctor: Patients with ICM are advised to monitor their condition regularly and follow all doctor's appointments.

Treatment of ICM should be individualized and depends on the specific circumstances and severity of the disease in each patient. [3]

Clinical Guidelines

Clinical recommendations for the management of ischemic cardiomyopathy (ICM) can vary depending on the severity of the disease, individual factors, and the patient's medical history. The following are general recommendations that are commonly used for the management of ICM:

1. Medication treatment:

   • Statins: Cholesterol-lowering drugs such as atorvastatin or simvastatin may be prescribed to reduce the risk of atherosclerosis and prevent the formation of new plaques in the arteries.
   • Blood pressure medications: If a patient has high blood pressure, medications to control it may be prescribed.
   • Medications to manage diabetes mellitus: If the patient has diabetes mellitus, treatment should be customized to control blood glucose levels.
   • Antithrombotic therapy: Aspirin and/or other drugs may be prescribed to prevent blood clots.

2. Treatment of cardiac rhythm disturbances: If a patient has ICM accompanied by arrhythmias, treatment may be needed to correct or control them.

3. Surgical treatment:

   • Coronary bypass surgery: If narrowed coronary arteries are present, coronary bypass surgery may be recommended to restore normal blood flow to the heart.
   • Angioplasty and stenting: Procedures to widen and keep narrowed arteries open.

4. Lifestyle changes:

   • Healthy eating: Following a diet that limits fat and salt can help control risk factors.
   • Physical activity: Regular exercise, supervised by your doctor, can strengthen your heart and blood vessels.
   • Smokingcessation: Smoking is a serious risk factor for ICM.
   • Stress Management: Practicing relaxation, meditation and maintaining psychological well-being can reduce stress and have a positive impact on heart health.

5. Regular follow-up with your doctor: Patients with ICM are advised to monitor their condition regularly and follow all doctor's orders.

6. Following yourdoctor's recommendations: It is important to cooperate with your doctor and follow his or her recommendations to achieve the best treatment and management results for this heart condition.

Treatment for ICM should be individualized, and patients should discuss their treatment plan with their physician to determine the best way to manage this condition.

Forecast

The prognosis of ischemic cardiomyopathy (ICM) depends on several factors, including the severity of the disease, the effectiveness of treatment, and the patient's adherence to lifestyle modification recommendations. Important factors affecting the prognosis of ICM include:

1. Degree of heart muscle damage: The more the heart muscle is damaged and degenerated, the less favorable the prognosis. Reduced heart function can lead to heart failure and reduced quality of life.
2. Time to start treatment: Early detection and initiation of effective treatment can significantly improve prognosis. Treatment includes drug therapy, angioplasty, coronary artery bypass grafting or even heart transplantation in cases of severe decompensation.
3. Control of risk factors: Controlling high blood pressure, lowering cholesterol, quitting smoking, controlling diabetes mellitus, and maintaining a healthy lifestyle can improve prognosis and slow the progression of ICM.
4. Lifestyle: Physical activity, a healthy diet, and stress management can reduce the burden on the heart and help improve prognosis.
5. Compliance with treatment: It is important to follow your doctor's recommendations and take prescribed medications. Improper management of the disease can worsen the prognosis.
6. Co-morbidities: The presence of other medical conditions, such as chronic kidney disease or diabetes mellitus, can worsen prognosis and complicate treatment.

The prognosis of ICM can vary from case to case. In some cases, with good control of risk factors and effective treatment, patients can live an active and quality life. In other cases, especially with severe cardiac decompensation and lack of effective treatment, the prognosis may be less favorable.

Causes of death

Ischemic cardiomyopathy is a serious heart disease that can lead to various complications and eventually cause the death of the patient. The leading cause of death in ICM is usually a complication such as:

1. Myocardial infarction (heart attack): One of the most dangerous complications of ICM. This condition occurs when blood flow in the coronary arteries of the heart is completely or partially blocked, resulting in necrosis of part of the heart muscle. If a myocardial infarction is not quickly attended to by medical measures, it can lead to death.
2. Heart Failure: ICM can cause chronic heart failure, in which the heart is unable to pump blood efficiently throughout the body. This condition can lead to poor health and eventually cause death.
3. Arrhythmias: ICM can cause cardiac arrhythmias such as atrial fibrillation or ventricular fibrillation. These arrhythmias can be dangerous and can be fatal.
4. Angina: ICM can cause angina (chest pain), which can lead to myocardial infarction or arrhythmias if left untreated.
5. Cardiac aneurysm and aortic dissection: These complications can also occur as a result of ICM and are life threatening.

The risk of death in ICM increases significantly if the patient does not receive timely and adequate treatment, does not control risk factors (e.g., blood pressure, cholesterol), does not monitor lifestyle and does not follow the doctor's recommendations.

Literature used

• Shlyakhto, E. V. Cardiology: national guide / ed. By E. V. Shlyakhto. - 2nd ed., revision and addendum - Moscow: GEOTAR-Media, 2021
• Cardiology according to Hurst. Volumes 1, 2, 3. 2023
• Ischemic cardiomyopathy. Paukov Vyacheslav Semyonovich, Gavrish Alexander Semyonovich. 2015